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Lazy Saturday Reads: Is The New York Times Morphing Into A Scandal Sheet?
Posted: July 25, 2015 | Author: bostonboomer | Filed under: morning reads, U.S. Politics | Tags: Clinton smears, New York Times |39 Comments
Early Friday morning, The New York Times published a story about Hillary Clinton on the front page below the fold. In it reporters Michael Schmitt and Matt Apuzo stated that–according to unnamed government sources–a criminal investigation into emails from Hillary Clinton's server was in the offing.
The story's lead soon had to be altered, and in the course of the yesterday, the story fell apart. Dylan Byers reported the changes at Politico at 4:58AM Friday.
New York Times alters Clinton email story.
The New York Times made small but significant changes to an exclusive reportabout a potential criminal investigation into Hillary Clinton's State Department email account late Thursday night, but provided no notification of or explanation for of the changes.
The paper initially reported that two inspectors general have asked the Justice Department to open a criminal investigation "into whether Hillary Rodham Clinton mishandled sensitive government information on a private email account she used as secretary of state."
That clause, which cast Clinton as the target of the potential criminal probe, was later changed: the inspectors general now were asking for an inquiry "into whether sensitive government information was mishandled in connection with the personal email account Hillary Rodham Clinton used as secretary of state."
The Times also changed the headline of the story, from "Criminal Inquiry Sought in Hillary Clinton's Use of Email" to "Criminal Inquiry Is Sought in Clinton Email Account," reflecting a similar recasting of Clinton's possible role. The article's URL was also changed to reflect the new headline.
As of early Friday morning, the Times article contained no update, notification, clarification or correction regarding the changes made to the article.
Whoever it is at the NYT who is making decisions based on Clinton hatred is making a laughing stock of what was once considered "the newspaper of record."
Salon: Another shoddy Clinton smear: Anatomy of the New York Times' epic email screw-up (emphasis added).
Late last night, The New York Times published an anonymously sourced reported, titled "Criminal Inquiry Sought in Hillary Clinton's Use of Email," that claimed two inspectors general asked the Justice Department to open a criminal investigation into whether the Democratic presidential frontrunner "mishandled" sensitive government information by using a personal email account and server while she was secretary of state. That story quickly fizzled by early Friday morning, with the Justice Department quashing talk of a criminal probe, although a new report claims Clinton sent at least four emails that contained classified intelligence community information from her private server while at the State Department.
A spokesperson for the Inspector General of the Intelligence Community confirmed to the Wall Street Journal that a review of 40 of the 30,000 emails Clinton has released from her time in office found that four "were classified when they were sent and are classified now." Clinton had previously claimed she never sent classified emails using her personal server, although the State Department has later acknowledged that some information in the messages should be retroactively classified.
But even that was incorrect, as reported Michael Schmidt had to admit on Hardball With Chris Matthews last night (thanks for Dakinikat for telling me about the MSNBC report. If you watch it, you'll learn that there never was any criminal investigation and that the emails in question were not even sent by Hillary. They were messages that may have been sent to her that contained information that probably should have been marked classified, but were not so marked.
The best part of the Matthews segment was his interview with Representative Elijah Cummings, who explained why the story is just plain B.S. and not worth the paper it was printed on. Here's the segment as posted on YouTube.
Back to the Salon story:
The Clinton campaign came out forcefully against the news, much swifter than they had with the initial round of New York Times reporting on the use of Clinton's email account, with a campaign spokesman railing against "reckless, inaccurate leaks from partisan sources." After allegedly receiving complaints on the report's accuracy from the Clinton campaign, The Times changed the article's title to "Criminal Inquiry Is Sought in Clinton Email Account,"and most crucially, walked back the claim that Clinton herself was the target of the probe. A spokesman for the campaign released a statement on Twitter early this morning blasting the report:
Contrary to the initial story, which has already been significantly revised, she followed appropriate practices in dealing with classified materials. As has been reported on multiple occasions, any released emails deemed classified by the administration have been done so after the fact, and not at the time they were transmitted."
Kurt Eichenwald at Newsweek: How The New York Times Bungled the Hillary Clinton Emails Story.
What the hell is happening at The New York Times?
In March, the newspaper published a highly touted article about Hillary Clinton's use of a personal email account that, as I wrote in an earlier column, was wrong in its major points. The Times's public editor defended that piece, linking to a lengthy series of regulations that, in fact, proved the allegations contained in the article were false. While there has since been a lot of partisan hullaballoo about "email-bogus-gate"—something to be expected when the story involves a political party's presidential front-runner—the reality remained that, when it came to this story, there was no there there.
Then, on Thursday night, the Times dropped a bombshell: Two government inspectors general had made a criminal referral to the Justice Department about Clinton and her handling of the emails. The story was largely impenetrable, because at no point did it offer even a suggestion of what might constitute a crime. By Friday morning, the Times did what is known in the media trade as a "skin back"—the article now said the criminal referral wasn't about Clinton but about the department's handling of emails. Still, it conveyed no indication of what possible crime might be involved.
The story seemed to further fall apart on Friday morning when Representative Elijah Cummings (D-Md.) issued a statement saying that he had spoken to the inspector general of the State Department and that there had been no criminal referral regarding Clinton's email usage. Rather, Cummings said, the inspectors general for State and the intelligence community had simply notified the Justice Department—which issues the regulations on Freedom of Information Act requests—that some emails subject to FOIA review had been identified as classified when they had not previously been designated that way.
But Eichenwald says the problems with he story "may" be even worse.
But based on a review of documents from the inspectors general, the problems with the story may be worse than that—much, much worse. The reason my last sentence says may is this: There is a possibility—however unlikely—that theTimes cited documents in its article that have the same dates and the same quotes but are different from the records I have reviewed. I emailed Dean Baquet, the Times's executive editor, to ask if there are some other records the paper has and a series of other questions, but received no response. (Full disclosure: I'm a former senior writer for the Times and have worked with Baquet in the past.)
So, in an excess of caution, I'm leaving open the possibility that there are other documents with the same quotes on the same dates simply because the other conclusion—that The New York Times is writing about records its reporters haven't read or almost willfully didn't understand—is, for a journalist, simply too horrible to contemplate.
Indeed, if the Times article is based on the same documents I read, then the piece is wrong in all of its implications and in almost every particular related to the inspector generals' conclusions. These are errors that go far beyond whether there was a criminal referral of Clinton's emails or a criminal referral at all. Sources can mislead; documents do not.
Please go read the whole thing at the link.
Media Matters' take on the story: The Unanswered Questions From The NY Times' Debunked Clinton Emails Report.
The New York Times' dramatic changes to their initial, anonymously-sourced claim that federal investigators were seeking a criminal probe into former Secretary of State Hillary Clinton's use of personal email raises significant questions about the paper's reporting of the story.
Read the whole thing at the link, but here are the questions:
"Who were the Times' sources?"
It's still unclear, but whoever they were they apparently burned the Times and they should be outed, according to a Media Matter source.
"Did the Times seek documentary evidence of the referrals for a criminal probe?"
The answer seems to be no.
"Did The Times Reach Out To Democrats On The Benghazi Committee Before Publication?"
Again the answer seems to be no. The story only quoted Republicans.
"Did The Times Reach Out To The Inspectors General Before Publication?"
Apparently not.
Quoting Kurt Eichenwald, "What the hell is happening at The New York Times?" Are they trying to become The New York Post? The powers that be at the Times need to start providing some answers.
What else is happening? Please post your thoughts and links on any topic in the comment thread and have a terrific weekend!
39 Comments on "Lazy Saturday Reads: Is The New York Times Morphing Into A Scandal Sheet?"
Andrea Mitchell also took apart the NYT story yesterday. Watch her report at Media Matters.
MSNBC's Andrea Mitchell Debunks Flimsy Times Article On Clinton Emails: "This Was Not A Criminal Referral."
Thx for following up with this Cummings just has had it with these Republicans lying about stuff and the NYT should apologize!
Matthews' did a great job on this. Thanks for alerting me to it.
Yes, he certainly did.
janicen says:
Excellent post, bb. It seems the only wrongdoing was on the part of the NYT. They absolutely should out their sources if in fact they were misled. Unless their sources are so obviously flimsy that they don't want to admit depending on them.
Most likely the sources are Republicans on the Benghazi committee, Gowdy and someone else.
I hope Cummings calls for an investigation to see who the sources are. BB is right that they are likely from Benghazi Committee. And I read this morning Gowdy is changed Hillary's date for hearing from May to October. What's up with that? Certainly makes my eyes roll.
When it comes to Hillary, the New York Times is the paper of (broken) record.
Prolix says:
Yet another example of the Foxification of all media. Fox's working the ref is paying off in that Fox no longer has to be at the scene of the crime of these bogus stories. They can then pick it up from there and spread it like the most maleficent manure.
As for the "government officials," they are hiding in plain sight — it is none other than the Gowdy Benghazi staff. After six investigations, it is most difficult to conjure evil doings where none exist. Schmitt's tentativeness is palpable in his defense of his inaccuracies — not exactly a profile in courage or journalistic ethics.
Exactly. I said the same thing above before I read your comment.
We need to call an investigation into the committee, and call Fox new to be investigated. They are running the republican campaigns, debate, and accepting money so that somebody can jump the ladder and get to the top of the debates. That's wrong.
The NYT has made far too many screwups — very unprofessional ones — on this story. They need to issue an apology.
Not holding my breath, though.
10 more trees on your street could make you feel 7 years younger, study shows
Leafy, tree-lined streets aren't just good for property values; they may also be good for your health, according to a new report.
After analyzing two sets of data from the city of Toronto, researchers report that adding just 10 trees to a single city block could improve how healthy a person feels as much as if they made an additional $10,000 a year or if they were seven years younger. The study in the journal Scientific Reports also found that residents of neighborhoods with higher tree density are less likely to have cardio-metabolic conditions such as hypertension, obesity and diabetes.
And it's not just that the well-to-do who live on tree-lined streets can afford a healthier lifestyle. The researchers controlled for demographic and socioeconomic factors and found that living near trees still had an effect on one's perception of health and overall health.
Boise is the "city of trees"………..I can't stand the clean up from all the damn trees around my house.
http://www.washingtonpost.com/blogs/the-fix/wp/2015/06/23/theres-a-new-poll-number-that-shows-just-how-likely-hillary-clinton-is-to-be-the-democratic-nominee/
Hah! Goes to show where all of this so called Bernie Sanders momentum is coming from. Not from Democrats!
Yay!!!! I enjoyed reading that, it was a pick-me-upper!!!!
…a desire to see Clinton tested in some way to prove that she is ready for what Republicans are going to throw at her.
I'd say the voters are already convinced she is ready!
Once upon a time the NYT was the epitome of excellent journalism, now it has become a rag, especially when it comes to any story about Hillary. Hillary has some powerful enemies that are determined to stop her run at the nomination and I fear that some of those enemies are on our side of the aisle. I want Hillary to become more visible, more vocal and more enthusiastic. She needs to bring everything she has to the table ASAP, or she may get pushed to the side like she did with Obama. The enthusiasm for Bernie Sanders worries me a bit, not because I don't like Sanders, but because it's the same sort of energy in the movement that I saw with Obama.
Hillary needs to get ahead on the enthusiasm curve. I know she doesn't want to light the candle too soon for fear of it burning out, but she needs to step things up a bit. I just don't see the passion for Hillary that I thought would be there and these hit pieces don't help. It's a lot easier for the NYT to publish damaging gossip, than it is to reel it back in.
BTW….My partner and I just ended one of the longest engagements on record, 31 years, when we got married on 7/15. It actually does feel different to be married, it feels FABULOUS!!!!
Congrats to you and your wife! And they said it wouldn't last!
Do you hang out at Still4Hill's place, too?
It's a great site to find out where Hillary is-everywhere-and how she's building her campaign.
Thank you Sweet Sue. I haven't visited Still4Hill, but I will start doing so. I am so excited about this campaign, but I don't feel the enthusiasm from others that I felt in 2008. And I'm worried that Bernie Sanders will grab up the momentum and it will be tough for Hillary to get it back. I wish she had attended Net Roots Nation so that there would have been the opportunity to contrast and compare, because I do believe Hillary would have responded appropriately to "Black lives Matter" or any other topic. I wasn't surprised that Bernie and O'Malley didn't get it right. O'Malley, imho, will fade fast, Bernie on the other hand, might not be quite as easy. I always remind people that Bernie, as much as I've admired his principled positions on economic and social issues, isn't a Democrat. He's an Independent Socialist and that's not a good label to take to the GE. I, personally, love Bernie's brand of socialism, but the word "socialism" will scare the bejeebus out of many people who only see bad in the word "socialist" and will never vote for him because of that label. It's time for Hillary, time for the first WOMAN POTUS and time for an Executive Branch that's built around a Woman's vision of America.
Still4Hill always has wonderful photos of Hillary as well as up-to-date information on her appearances and speeches.
HillaryMen is another great site. It's run by long-time Hillary supporters Peter Daou and Tom Watson. Here's their latest essay:
http://www.hillarymen.com/latest/new-york-times-has-a-serious-hillary-clinton-problem
List of X says:
Congratulations, and may your marriage last long enough to set the record for marriages, too. 🙂
Thank you, but I think we're a bit too old to set that record. We have friends who got married 3 days after the SCOTUS decision, they've been together 65 years. When we went to get our license the Clerk told us that she'd only had a few couples that had been together longer than us. One of the couples were our friends, the other couples had been together 50+ years and 40+ years. As far as I'm concerned we've all set records. It's not easy to stay together for decades when your family and most of society doesn't want you to be together in the first place. I suppose that's where stubbornness pays dividends! We were determined to stay together, in spite of it all. 🙂
May you have many more happy years together!
Thank you Luna!
That's a long time, congrats to you both. I have a lot of respect for you both, a red rose for the both of you.
Thank you Fannie.
I hope you had a wonderful wedding and honeymoon, Mouse! It's good to have you back at the blog. You've been missed.
It's early days yet for Hillary's campaign. I think enthusiasm for her will build. Our girl is going to outshine all her opponents during the debates! No doubt about that.
Thank you Beata, we had a wonderful time. And I've missed reading and commenting with the Sky Dancers. Y'all are my internet family.
And I agree that Hillary will "outshine" the competition in the debates. I just would like to see more of her, more enthusiasm for her and I want to see big crowds at her events. I know she doesn't want to ramp it up to much this far out, but I'm getting restless. We need President Hillary.
I'm so happy for you and your wife. It's great to have you back. We missed you!
Thank you, Janicen. I missed you all too!
Delphyne49 says:
Congratulations, Mouse!! So happy for you and your wife!!
Thank you Delph…..We're still celebrating. We're might just celebrate from here on out. 🙂
Congratulations to you, Mouse! I'm glad you're back. All the best to you and your partner in the years to come.
Thank you very much BB. And I'm glad to be back reading & commenting on Sky Dancing. I was only able to connect to the internet once from our hotel, the Wi-Fi signal was so weak I finally gave up. It was good to be able to read this post yesterday morning, it's an excellent post by the way.
Here is a fun story: Pentagon is unhappy with armed civilians showing up to "guard" recruiting centers: http://www.npr.org/sections/thetwo-way/2015/07/25/426146861/pentagon-asks-armed-citizens-not-to-stand-guard-at-recruiting-centers
BRATTON ORDERS REVIEW OF NYPD TRAINING AFTER DEATH OF ERIC GARNER
http://7online.com/news/nypd-takes-gun-badge-away-from-officer-who-placed-man-in-chokehold/197357/
NW Luna on Wednesday Inauguration Reads:…
'Come with me if you want to live': Schwarzenegger gets vaccinated (Alexander Nieves/Politico)
Twitch has 'indefinitely' banned Donald Trump (Bijan Stephen/The Verge)
The Republican Future Starts Now (Karl Rove/Wall Street Journal)
Former GOP operative Michael Ellis placed on administrative leave from NSA top lawyer job (Ellen Nakashima/Washington Post)
Army falsely denied Flynn's brother was involved in key part of military response to Capitol riot (Washington Post)


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Home Art Show SF – Pashmina Art Show Closing Reception
SF – Pashmina Art Show Closing Reception
The Cartoon Art Museum welcomes Nidhi Chanani, the inaugural artist in the Cartoon Art Museum's Emerging Artist Showcase, for a closing reception celebrating her debut graphic novel Pashmina. Chanani will meet museum patrons and sign copies of Pashmina on Sunday, February 11, 2018 from 2:00 – 4:00 PM. This event is included with paid admission to the Cartoon Art Museum.
About Nidhi Chanani:
Nidhi Chanani was born in Kolkata, India, and raised in Southern California. She holds a degree in literature from the University of California, Santa Cruz. She creates illustrations that capture the love in everyday moments. In 2012, she was honored at the White House as a Champion of Change for her art. Her illustrations are sold in boutiques along the West Coast and she has worked with companies like Disney and Hasbro. Nidhi lives in the San Francisco Bay area with her husband, daughter, and two cats. Pashmina is her first graphic novel.
About Pashmina:
Priyanka Das has so many unanswered questions: Why did her mother abandon her home in India years ago? What was it like there? And most importantly, who is her father, and why did her mom leave him behind? But Pri's mom avoids these questions―the topic of India is permanently closed.
For Pri, her mother's homeland can only exist in her imagination. That is, until she find a mysterious pashmina tucked away in a forgotten suitcase. When she wraps herself in it, she is transported to a place more vivid and colorful than any guidebook or Bollywood film. But is this the real India? And what is that shadow lurking in the background? To learn the truth, Pri must travel farther than she's ever dared and find the family she never knew.
In this heartwarming graphic novel debut, Nidhi Chanani weaves a tale about the hardship and self-discovery that is born from juggling two cultures and two worlds.
About The Emerging Artists Showcase:
The Cartoon Art Museum's Emerging Artist Showcase is dedicated to the presentation of new and emerging voices in comics, from the San Francisco Bay Area and beyond. This ongoing series of exhibitions is curated by the Cartoon Art Museum and supported in part by the Zellerbach Family Foundation.
ABOUT THE CARTOON ART MUSEUM
The Cartoon Art Museum's mission is to ignite imaginations and foster the next generation of visual storytellers by celebrating the history of cartoon art, its role in society, and its universal appeal. The museum's vision is to be the premier destination to experience cartoon art in all its many forms from around the world, and a leader in providing insight into the process of creating it.
781 Beach Street, San Francisco, CA 94109
comicmarket
Nidhi Chanani
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redpajama_set_name: RedPajamaCommonCrawl


This critically acclaimed restaurant had a reasonable stream of customers, but needed to increase their patrons frequency to fill their restaurant. The restaurant wanted to have a regular clientele that returned often and were loyal to their business, and also bought friends and colleagues along with them. The restaurant also organised and catered for corporate events, but this service didn't have many clients, so the restaurant wanted to start promoting it to their existing clients.
Sales - the restaurant wanted to increase their sales by encouraging customers to become regulars, and also by promoting their corporate events services.
Customer relations - in order to improve their relationships with their regular customers, the restaurant wanted to establish a VIP program to offer special deals and events to these customers to show their appreciation.
Leads - the restaurant wanted to encourage their current customers to spread the word about their business to their friends and family.
Promoted their website address on tables - in order to increase the traffic to their website and to collect contacts for their database, the restaurant designed cards to place on the table for each group of customers. The card featured the website address and spaces for all the people at the table to write down their email addresses for the mailing list. Every person that submitted their email address was given a free coffee with their meal. This strategy helped the restaurant grow their database to hundreds of contacts within only a few weeks, and also increased traffic to their website.
Established a network of alliances - this restaurant got together with local businesses and their suppliers to form an alliance network. This alliance was established because these businesses all had a similar target audience and wanted to combine their marketing efforts. They advertised in and shared stories for each other's newsletters, organised combined events and offered special deals to customers of the other businesses. This alliance worked well for restaurant because it gave them access to a whole new group of prospects, and also allowed them to offer more to their VIP clients.
Sent out a regular newsletter - in order to keep their business at the top of their clients' minds, the restaurant sent out a monthly newsletter to their database of contacts. The newsletter contained fun local, upcoming events, a recipe from their chef, an idea for a corporate function theme or private party, and a story or offer from two of their alliances. Because they had a balance of sales and general content, the newsletters were widely read. The restaurant also sent out special marketing pieces with information about their corporate events to their restaurant customers to raise awareness of their other service.
Created an online menu - the website's traffic was growing and in order to entice these people to visit the restaurant, the restaurant photographed all of their meals and then uploaded these pictures onto a menu on the website. The menu photos attracted a lot of visitors, and many new customers mentioned the photos when they visited the restaurant.
Created an online photo gallery for their patrons and corporate events - the restaurant hired a professional photographer to take photos at the restaurant each evening and at their corporate events. The restaurant then made these pictures available for viewing and purchase on their website. This helped to promote their corporate events services to their restaurant customers and also to increase their website traffic.


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Research article | Open | Open Peer Review | Published: 22 August 2018
Serum potassium as a predictor of adverse clinical outcomes in patients with chronic kidney disease: new risk equations using the UK clinical practice research datalink
Hans Furuland1,
Phil McEwan2,3,
Marc Evans4,
Cecilia Linde5,
Daniel Ayoubkhani2,
Ameet Bakhai6,
Eirini Palaka7,
Hayley Bennett2 &
Lei Qin8
To address a current paucity of European data, this study developed equations to predict risks of mortality, major adverse cardiac events (MACE) and renin angiotensin-aldosterone system inhibitor (RAASi) discontinuation using time-varying serum potassium and other covariates, in a UK cohort of chronic kidney disease (CKD) patients.
This was a retrospective observational study of adult CKD patients listed on the Clinical Practice Research Datalink, with a first record of CKD (stage 3a–5, pre-dialysis) between 2006 and 2015. Patients with heart failure at index were excluded. Risk equations developed using Poisson Generalized Estimating Equations were utilised to estimate adjusted incident rate ratios (IRRs) between serum potassium and adverse outcomes, and identify other predictive clinical factors.
Among 191,964 eligible CKD patients, 86,691 (45.16%), 30,629 (15.96%) and 9440 (4.92%) experienced at least one hyperkalaemia episode, when defined using serum potassium concentrations 5.0–< 5.5 mmol/L, 5.5–< 6.0 mmol/L and ≥ 6.0 mmol/L, respectively. Relative to the reference category (4.5 to < 5.0 mmol/L), adjusted IRRs for mortality and MACE exhibited U-shaped associations with serum potassium, with age being the most important predictor of both outcomes (P < 0.0001). A J-shaped association between serum potassium and RAASi discontinuation was observed; estimated glomerular filtration rate was most predictive of RAASi discontinuation (P < 0.0001).
Hyperkalaemia was associated with increased mortality and RAASi discontinuation risk. These risk equations represent a valuable tool to predict clinical outcomes among CKD patients; and identify those likely to benefit from strategies that treat hyperkalaemia, prevent RAASi discontinuation, and effectively manage serum potassium levels.
Hyperkalaemia, typically defined as serum potassium concentration exceeding 5.0 mmol/L, is a potentially life-threatening electrolyte imbalance [1]. Recent epidemiological studies have consistently demonstrated associations between hyperkalaemia and adverse clinical outcomes; notably hospitalisation, cardiovascular morbidity and mortality [2,3,4,5,6].
As a consequence of impaired renal function, patients with chronic kidney disease (CKD) are at increased risk of hyperkalaemia; and renin-angiotensin-aldosterone system inhibitor (RAASi) agents routinely indicated for CKD management [1, 7] are known to exacerbate this risk [8]. Despite this, the current practice of down-titrating or discontinuing guideline-recommended RAASi therapy in response to acute hyperkalaemia [9, 10] has recently been associated with worsening clinical outcomes and greater total costs in patients with CKD or other comorbidities [11,12,13,14].
Real-world studies associating serum potassium and adverse clinical outcomes in CKD patients, including death, major adverse cardiac events (MACE), hospitalisation and RAASi discontinuation, have previously been conducted in the US [2,3,4,5,6]. In contrast to other industrialised countries, healthcare in the US is largely privatised, and the availability of clinical data may be limited by the size, length and claims-based nature of US healthcare records. Thus, it is unclear whether existing data describing the epidemiology and burden of hyperkalaemia may be generalisable to a European CKD population. Using primary care data obtained from the Clinical Practice Research Datalink (CPRD) [15], this study sought to develop risk equations describing the relationship between serum potassium concentration and incidence of death, MACE and RAASi discontinuation, in a contemporary UK cohort of CKD patients.
Study data and patient population
This retrospective analysis utilised data from the CPRD and linked Hospital Episode Statistics (HES). The CPRD is an observational research database comprised of anonymised, longitudinal primary care records for approximately 7% of the UK population. It is broadly representative of the general population, and is the world's largest computerised database of medical records suitable for public health research [16]. Linked HES data described admissions, outpatient appointments, and emergency episodes in National Health Service hospitals in England [17]. The study was approved by the Independent Scientific Advisory Committee for Medicines and Healthcare Products Regulatory Agency database research on 15 December 2016 (study protocol 16_223R).
Inclusion criteria for the study were adult CKD patients (aged ≥18 years) in the CPRD between 1 January 2006 and 31 December 2015, who experienced a first record of CKD (stage 3a to 5, pre-dialysis; herein referred to as the index date) after the study start date. Patients were selected on the basis of estimated glomerular filtration rate (eGFR; defined as < 60 mL/min/1.73m2 [7]), Read codes (CPRD), and ICD-10 codes (HES). Exclusion criteria comprised patients on dialysis at index date or with a CKD event prior to 1 January 2006, and patients with a history of heart failure (HF; identified by Read and ICD-10 codes) at index date, due to the increased risk of hyperkalaemia associated with RAASi usage [9]. Read and ICD-10 codes were further used to define clinical outcomes and covariates (Additional file 1: Table S1).
Study design and data structuring
The clinical outcomes studied in this analysis included all-cause mortality, incidence of MACE (myocardial infarction, arrhythmia, HF, and stroke), and discontinuation of RAASi medications. Using the medicines possession ratio, RAASi discontinuation was defined as the first 90-day gap after the estimated end-date of a RAASi prescription. Agents comprising RAASi therapy included angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), mineralocorticoid receptor antagonists (MRAs), and renin inhibitors. Hyperkalaemia was defined according to serum potassium intervals of ≥5.0 mmol/L to < 5.5 mmol/L, ≥5.5 mmol/L to < 6.0 mmol/L, and ≥ 6.0 mmol/L. Serum potassium < 3.5 mmol/L was classified as hypokalaemia.
Serum potassium was time-updated during the follow-up period; an illustrative example of this methodology is provided in Additional file 1 and Additional file 2: Figure S1. In brief, each patient's most recent serum potassium measurement was applied until a new measurement became available, using a last-observation-carried-forward (LOCF) approach [4]. Further, time-updated eGFR readings were the most recently available at the time of each serum potassium measurement. The period between serum potassium measurements defined patient-intervals, and clinical events of interest were assigned to these based on the date on which they occurred.
Time-updated serum potassium was evaluated categorically (< 3.5, 3.5 to < 4.0, 4.0 to < 4.5, 4.5 to < 5.0, 5.0 to < 5.5, 5.5 to < 6.0, and ≥ 6.0 mmol/L). Exposure time in each serum potassium category was quantified in patient-years. Patients were followed up to and including the first occurrence of loss to follow-up, end of study period (31 December 2015), or death.
The data were analysed using R version 3.3.2 [18]. Means, medians, counts and/or proportions, and associated measures of variability were used to describe patient demographics. Patient characteristics at index date were used to calculate summary statistics; baseline clinical measurements were defined as the first measurement taken in the 3 months following the index date. Disease history was analysed over the 5 years prior to the index date and was expressed using counts and proportions. Medication usage at baseline was defined as having at least one prescription during a six-month period centred around the index date and expressed as counts and proportions. Missing values were not included in calculations relating to baseline patient characteristics, disease history and medication usage.
Hyperkalaemia episodes of increasing severity were defined as serum potassium measurements within each interval (≥5.0 mmol/L to < 5.5 mmol/L, ≥5.5 mmol/L to < 6.0 mmol/L, and ≥ 6.0 mmol/L), without a hyperkalaemic measurement of at least that severity (serum potassium ≥5.0 mmol/L, ≥5.5 mmol/L, and ≥ 6.0 mmol/L, respectively) in the preceding 7 days. Subsequently, hyperkalaemia episodes were assumed to persist for a maximum duration of 1 week. The median time between successive episodes was calculated among only those patients who experienced the given number of episodes; censoring due to death, loss to follow-up or end of study period was not taken into account.
The incidence of each outcome (death, MACE and RAASi discontinuation) was predicted using a risk equation obtained by fitting a statistical model to the event count in each patient-interval. Risk equations were estimated using Generalized Estimating Equations with an exchangeable working correlation structure to account for intra-patient correlation. Events were assumed to be Poisson distributed. Risk equations included a natural logarithm link function and an offset equal to the natural logarithm of patient-years (defined as the exposure time in each patient-interval). Patients with a serum potassium of 4.5 to < 5.0 mmol/L were used as the reference group for comparison, from which incident rate ratios (IRRs) were estimated.
To address the possibility of long durations between measurements of serum potassium and the incidence of death, MACE and RAASi discontinuation, adjusted IRRs were re-estimated after restricting patient-intervals to a maximum of 30 days post-potassium measurement. Additional sensitivity analysis explored the relationship between CKD stage and observed associations between serum potassium and clinical outcomes, by estimating adjusted IRRs in CKD patients stratified according to time-updated eGFR: 45 to < 60 mL/min/1.73m2 (CKD 3a); 30 to < 45 mL/min/1.73m2 (CKD 3b); 15 to < 30 mL/min/1.73m2 (CKD 4); < 15 mL/min/1.73m2 (CKD 5).
Multiple imputation was used to inform missing baseline measurements when estimating the risk equations, which were carried forward using LOCF. Five multiply imputed datasets were produced; model coefficients and their standard errors were pooled across datasets using Rubin's Rules [19], in order to capture the variance of the coefficients both within and between the imputed datasets. Using the method of Chained Equations, as implemented in the R package 'mice' [18], multiple imputation was performed on all clinical variables with all candidate covariates and outcome variables from the analysis models included in the imputation models.
Model assessment and final selection was informed by the Quasi-Likelihood Information Criterion on a randomly selected training sub-sample, and the prediction mean squared error on a randomly-selected validation sub-sample [20]. Predicted incidence rates and IRRs were adjusted for covariates, included as explanatory variables in the risk equations. Adjusted IRRs relating serum potassium to the incidence of mortality and MACE estimated by the fitted risk equations were validated against those published by Luo et al. [4]: a real-world study of CKD stage 3+ patients of similar design to the present study, but using data collected in the US.
Patient demographics and characteristics at baseline
The analysed cohort consisted of 191,964 eligible CKD patients, with a mean follow-up time of 4.96 years (Fig. 1; Table 1). At baseline, the mean age was 72.48 years, the majority of the cohort was female (60.61%), and diabetes was the most prevalent comorbidity (14.63%). Based on the earliest measurement recorded in the first 3 months post-index, mean eGFR was 50.96 mL/min/1.73m2 and mean serum potassium was 4.47 mmol/L. When patients were stratified by serum potassium category at baseline, the proportion of female patients in each subgroup decreased from 68.50% (< 3.5 mmol/L category) to 53.22% (≥6.0 mmol/L category).
Study participation flow diagram. CKD: chronic kidney disease; CPRD: Clinical Practice Research Datalink; eGFR: estimated glomerular filtration rate; HF: heart failure; ICD: International Classification of Diseases
Table 1 Baseline patient demographics and clinical histories of chronic kidney disease patients, stratified by serum potassium category
Approximately half of patients (48.06%) received RAASi therapy, with ACE inhibitors being the most commonly used agent (35.36%). When stratified according to baseline serum potassium, patients with increasing potassium levels were typically more likely to receive ACE inhibitors, ARBs and MRAs. Other frequently prescribed medications included statins (43.14%), diuretics (40.19%), β-blockers (25.30%), and dihydropyridine calcium channel blockers (23.78%).
In the absence of CKD-specific dosing guidelines, Table 2 presents the proportion of patients who received RAASi agents at doses recommended in European Society of Cardiology guidelines for heart failure management [9]. Over one-third of patients receiving ACE inhibitors or MRAs (36.11% and 36.02%, respectively) achieved the target maintenance dose for these therapies; in contrast, 3.28% of those receiving ARBs achieved the target dose. The majority of ARB-treated patients (59.48%) achieved less than 50% of the recommended target dose, compared to 37.38% of patients receiving ACE inhibitors. No patients in receipt of MRAs achieved less than 50% of the recommended target dose.
Table 2 Renin-angiotensin-aldosterone system inhibitor use at baseline, relative to target maintenance doses recommended by European Society of Cardiology guidelines for heart failure management [9]
Serum potassium and hyperkalaemia
Using serum potassium intervals of ≥5.0 mmol/L to < 5.5 mmol/L, ≥5.5 mmol/L to < 6.0 mmol/L, and ≥ 6.0 mmol/L to define hyperkalaemia of increasing severity, 86,691 (45.16%), 30,629 (15.96%) and 9440 (4.92%) patients experienced at least one episode over the follow-up period, respectively (Table 3). Based on these serum potassium thresholds, crude incidence rates of hyperkalaemia were 246.02, 62.66 and 15.00 events per 1000 patient-years, respectively. Hyperkalaemia recurrence exhibited a notable pattern; time intervals between successive episodes of serum potassium ≥5.0 mmol/L to < 5.5 mmol/L decreased from 1.80 years (time to first episode), to 0.99 years (first to second episode), to 0.76 years (second to third episode), and to 0.61 years (third to fourth episode). Similar patterns held true when hyperkalaemia was defined according to serum potassium intervals of ≥5.5 mmol/L to < 6.0 mmol/L and ≥ 6.0 mmol/L.
Table 3 Incidence and median time between hyperkalaemia episodes
Incidence of death, MACE, and RAASi discontinuation
In total, 44,961 deaths, 80,038 MACE and 75,488 RAASi discontinuation events were observed over the follow-up period, which corresponded to crude event rates of 47, 84 and 79 per 1000 patient-years, respectively (Additional file 1: Table S2).
When considering the full duration of patient-intervals between serum potassium measurements, adjusted IRRs for death exhibited a U-shaped association with categorical serum potassium levels (Fig. 2a). Relative to the reference category of 4.5 to < 5.0 mmol/L, serum potassium < 4.0 mmol/L and ≥ 5.0 mmol/L were each associated with increased mortality risk. Among patients with serum potassium ≥5.5 mmol/L to < 6.0 mmol/L, the adjusted IRR for mortality was 1.60 (95% CI: 1.52–1.68) compared with the reference category, which increased to 2.88 (2.61–3.18) in patients with serum potassium ≥6.0 mmol/L. In validation, the U-shaped association pattern between potassium and mortality observed in this study was similar to that published by Luo et al. [4] (Additional file 3: Figure S2); in the case of the latter, an adjusted IRR of 1.60 (1.37–1.88) was estimated for patients with serum potassium ≥5.5 mmol/L to < 6.0 mmol/L (as observed in our study), but a somewhat larger IRR of 3.31 (2.52–4.34) was estimated for patients with serum potassium ≥6.0 mmol/L (compared to 2.88 in our study).
Adjusted incident rate ratios for death (a), MACE (b) and RAASi discontinuation (c) as a function of serum potassium in CKD patients. Black: full patient-intervals; grey: patient-intervals restricted to 30 days. Incident rate ratios were adjusted to account for confounding patient demographics, clinical histories and comorbidities, clinical measurements, and medication usage, as reported in Table 4 and Additional file 1 : Table S3. CKD: chronic kidney disease; MACE: major adverse cardiac event; RAASi: renin-angiotensin-aldosterone system inhibitor. Error bars represent 95% confidence intervals
Similar to mortality, serum potassium levels < 4.0 mmol/L were associated with increased risks of MACE when the full duration of patient-intervals were utilised (Fig. 2b). However, confidence intervals relating to serum potassium ≥5.0 mmol/L contained an IRR of unity, reflecting increased uncertainty of the association between hyperkalaemia and MACE. Relative to the reference category, adjusted IRRs for MACE were 1.07 (1.00–1.15) and 1.15 (0.98–1.36) for patients with serum potassium ≥5.5 mmol/L to < 6.0 mmol/L and ≥ 6.0 mmol/L, respectively. In validation, the association between serum potassium and MACE estimated by Luo et al. [4] exhibited a more pronounced U-shaped pattern than that observed in our study (Additional file 3: Figure S2), with larger and statistically significant adjusted IRRs of 1.12 (1.05–1.20) and 1.88 (1.66–2.12) for patients with serum potassium ≥5.5 mmol/L to < 6.0 mmol/L and ≥ 6.0 mmol/L, respectively.
Associations between adverse event risk and serum potassium concentration were more pronounced after restricting patient-intervals to a maximum of 30 days from each serum potassium measurement. Relative to the reference category, adjusted IRRs for patients with serum potassium ≥5.5 mmol/L to < 6.0 mmol/L were estimated as 2.03 (1.84–2.23) and 0.97 (0.89–1.06) for mortality and MACE, respectively; these increased to 4.39 (3.88–4.97) and 1.29 (1.08–1.55), respectively, among patients with serum potassium ≥6.0 mmol/L.
The association between categorical serum potassium and the incidence of RAASi discontinuation was observed to be J-shaped (Fig. 2c). Based on the full duration of patient-intervals between serum potassium measurements, adjusted IRRs for RAASi discontinuation were estimated as 1.47 (1.42–1.53) for patients with serum potassium ≥5.5 mmol/L to < 6.0 mmol/L, and increased to 2.79 (2.61–2.99) among those with serum potassium ≥6.0 mmol/L, when compared to the reference category. Following restriction of patient-intervals to a maximum of 30 days from each serum potassium measurement, adjusted IRRs for RAASi discontinuation increased to 1.90 (1.79–2.03) and 4.37 (3.99–4.79) among patients with serum potassium ≥5.5 mmol/L to < 6.0 mmol/L and ≥ 6.0 mmol/L, respectively.
Observed associations between serum potassium and clinical outcomes were preserved when patients were stratified by CKD stage in sensitivity analyses (Additional file 4: Figure S3). Adjusted IRRs for mortality, MACE and RAASi discontinuation in patients with CKD 3a, CKD 3b, CKD 4 and CKD 5 demonstrated similar trends to one another and to the overall cohort; however, smaller sample sizes gave rise to wider confidence intervals and greater uncertainty, particularly for patients with eGFR < 15 mL/min/1.73m2.
Table 4 summarises coefficient estimates and statistical inferences relating to the final fitted risk equations. In addition to serum potassium concentration, age and sex were significant risk factors for both death and MACE (P < 0.0001). Death was also significantly associated with RAASi usage, time with CKD and eGFR, while history of MACE of baseline was a significant risk factor for MACE during follow-up (all P < 0.0001). For RAASi discontinuation, the most important risk factors were eGFR, diuretics usage, diabetes status and sex (all P < 0.0001). Coefficient estimates and statistical inferences obtained after re-estimating the equations on patient-intervals restricted to a maximum of 30 days are provided in Additional file 1 (Table S3).
Table 4 Model output for final risk equations
To illustrate the predictive outputs of the risk equations, Fig. 3 presents the expected rates of death (per 1000 patient-years) as a function of serum potassium level. Predicted mortality rates were further disaggregated by the four most important predictive factors: age, RAASi usage, time with CKD and eGFR (Fig. 3a, b, c and d, respectively). Similarly, association patterns between serum potassium and MACE incidence, disaggregated by age, history of MACE, time from index and sex, are illustrated in Fig. 4a, b, c and d, respectively. Expected rates of RAASi discontinuation according to serum potassium level are presented in Fig. 5, disaggregated by eGFR, diuretics usage, diabetes status and sex (Fig. 5a, b, c and d, respectively).
Predicted incidence rates of death, disaggregated by age (a), RAASi usage (b), time from index (c) and eGFR (d). a light grey line: 60 years, dark grey line: 70 years, black line: 80 years. b grey line: not prescribed, black line: prescribed. c light grey line: 1 year, dark grey line: 5 years, black line: 10 years. d light grey line: 15 mL/min/1.73m2, dark grey line: 30 mL/min/1.73m2, black line: 60 mL/min/1.73m2. The four most important variables for each event (according to the absolute value of the t statistic) were varied, with all other baseline covariates reflective of the cohort average: female; aged 72 years; non-smoker; no history of comorbidities; no medications prescribed; 1066 days elapsed since initial CKD event; no history of heart failure during follow-up period; eGFR 51 mL/min/1.73m2; BMI 29 kg/m2; haemoglobin 13.6 g/dL; total cholesterol 4.98 mmol/L. BMI: body mass index; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; RAASi: renin-angiotensin-aldosterone system inhibitor
Predicted incidence rates of MACE, disaggregated by age (a), history of MACE (b), time from index (c) and sex (d). a light grey line: 60 years, dark grey line: 70 years, black line: 80 years. b grey line: yes, black line: no. c light grey line: 1 year, dark grey line: 5 years, black line: 10 years. d grey line: male, black line: female. The four most important variables for each event (according to the absolute value of the t statistic) were varied, with all other baseline covariates reflective of the cohort average: female; aged 72 years; non-smoker; no history of comorbidities; no medications prescribed; 1066 days elapsed since initial CKD event; no history of heart failure during follow-up period; eGFR 51 mL/min/1.73m2; BMI 29 kg/m2; haemoglobin 13.6 g/dL; total cholesterol 4.98 mmol/L. BMI: body mass index; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; MACE: major adverse cardiac event
Predicted incidence rates of RAASi discontinuation, disaggregated by eGFR (a), diuretics usage (b), presence of diabetes (c), and sex (d). a light grey line: 15 mL/min/1.73m2, dark grey line: 30 mL/min/1.73m2, black line: 60 mL/min/1.73m2. b grey line: yes, black line: no. c grey line: yes, black line: no. d grey line: male, black line: female. The four most important variables for each event (according to the absolute value of the t statistic) were varied, with all other baseline covariates reflective of the cohort average: female; aged 72 years; non-smoker; no history of comorbidities; no medications prescribed; 1066 days elapsed since initial CKD event; no history of heart failure during follow-up period; eGFR 51 mL/min/1.73m2; BMI 29 kg/m2; haemoglobin 13.6 g/dL; total cholesterol 4.98 mmol/L. BMI: body mass index; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; RAASi: renin-angiotensin-aldosterone system inhibitor
Using real-world data from 191,964 CKD patients in the UK, we derived risk equations that may be used in clinical practice to relate serum potassium and other predictive factors to the incidence of mortality, MACE and RAASi discontinuation. Adjusted IRRs derived in this analysis demonstrated U-shaped associations between serum potassium and the risks of mortality and MACE (though not as strongly in the case of the latter); and a J-shaped association between serum potassium and the incidence of RAASi discontinuation. Other statistically important predictors of adverse clinical outcomes included age and sex, time with CKD, RAASi usage, eGFR, and history of MACE. The risk equations presented here represent a valuable tool to identify CKD patients at increased risk of adverse clinical outcomes; and those most likely to benefit from strategies that avoid hyperkalaemia, prevent RAASi discontinuation, and effectively maintain serum potassium homeostasis.
Our findings are broadly consistent with literature reporting relationships between hypo- and hyperkalaemia and worsening clinical outcomes in CKD patients [2,3,4,5]. In particular, mortality risk was lowest among patients with serum potassium between 4.0–5.0 mmol/L; an optimal range similarly identified in recent US studies associating serum potassium with all-cause mortality in patients with and without CKD, HF and/or diabetes [6], and those examining in-hospital mortality risk among hospitalised patients with CKD and/or cardiovascular disease [21]. Other US studies have also demonstrated significant relationships between all-cause mortality and both hypo- (< 3.5 mmol/L) and hyperkalaemia (> 5.0 mmol/L) in patients with CKD stages 3–4 [22]; and between both all-cause mortality and hospital admissions and hyperkalaemia (> 5.0 mmol/L) in cardiovascular disease patients treated with antihypertensive medications that impair potassium homeostasis [23]. Although cause of death was not explored in our analysis due to a paucity of relevant CPRD data, a previous study of CKD patients with coronary artery disease found that the risk of sudden cardiac arrest and death doubled when serum potassium measurements taken before the event exceeded 5.0 mmol/L [24].
Additional sensitivity analyses found that observed relationships between serum potassium and mortality, MACE and RAASi discontinuation were preserved when patients were stratified by CKD stage, with little variation in the association patterns between stages. This finding is consistent with a similar study by Luo et al., who found no significant interaction between eGFR and serum potassium when predicting mortality in a US CKD 3+ population [4]. However, it is noteworthy that observed relationships between serum potassium and risks of mortality and MACE in the overall CKD cohort were comparatively weaker than those estimated by Luo et al. [4]. While our study examined an incident CKD cohort, associations reportered herein may have been strengthened by the inclusion of a prevalent CKD population. Death within 30 days of MACE occurred for approximately 2% of MACE events recorded in this study; therefore, relationships between serum potassium and MACE may be underestimated, due to potential under-reporting of fatal MACE in primary care and a lack of cause of death data. Moreover, although previous studies have generally found that deaths recorded on the CPRD are in concordance with Office for National Statistics national mortality registrations [25], less is known about the reverse. However, an important consideration is the difference in contextual settings and populations captured by each database, particularly regarding patient demographics, clinical characteristics, treatment paradigms and healthcare systems. One notable strength of our study is the use of the CPRD, which contains primary care data for a large, diverse population with access to publicly-funded healthcare. Compared to existing US data, it could therefore be suggested that our results are more generalisable to other countries and healthcare systems, particularly those across Europe.
We demonstrated a J-shaped association pattern between serum potassium and RAASi discontinuation risk. Adjusted IRRs reported here relate to RAASi discontinuation rates estimated among all patients and intervals observed during the study period. However, when alternative definitions of RAASi exposure were investigated (such as only including patients in receipt of RAASi over the duration of the follow-up period, or intervals where a RAASi therapy had been prescribed), the association pattern between serum potassium levels and the likelihood of RAASi discontinuation was preserved. This J-shaped association is consistent with prescribing guidelines, where hyperkalaemia risk among patients treated with RAASi is commonly managed through the down-titration or discontinuation of such potassium-retaining agents [9, 10]. When delivered at guideline-recommended doses, RAASi have been evidenced to control blood pressure, delay disease progression and improve long-term outcomes in CKD patients [7, 9, 26,27,28]; however, suboptimal dosing has conversely been associated with increased adverse event risks and healthcare costs [11,12,13,14]. Consequently, strategies to control serum potassium and avoid RAASi discontinuation represent an important advance in CKD management, and have significant potential to improve health economic outcomes. The risk equations generated in this study are intended to inform the potential value of maintaining normal serum potassium levels in CKD patients, and identify clinical factors that place patients at greater risk of RAASi discontinuation, MACE and death.
There is no single definition of hyperkalaemia; therefore, comparisons of incidence and outcomes across epidemiological studies are often obscured by inconsistent serum potassium thresholds. As shown in this study, the incidence of hyperkalaemia was highly sensitive to the serum potassium threshold used to define it; and estimated IRRs of death, MACE and RAASi discontinuation were higher with increasing serum potassium levels. Had the sample size allowed for such analysis, we believe that further stratification of patients with serum potassium ≥6.0 mmol/L would have strengthened the association pattern between serum potassium and adverse event risk. Nevertheless, our results highlight the importance of a standardised definition of hyperkalaemia, to facilitate valid comparisons between observational studies and across different populations.
To our knowledge, few studies have examined the time between successive hyperkalaemia episodes in patients with recurrent hyperkalaemia. A noteworthy pattern observed in our analyses was the shortening of intervals between successive hyperkalaemia episodes, irrespective of the serum potassium intervals used to define events of increasing severity (≥5.0 mmol/L to < 5.5 mmol/L, ≥5.5 mmol/L to < 6.0 mmol/L, and ≥ 6.0 mmol/L). Given the impact of hyperkalaemia on patient morbidity, mortality and associated resource utilisation, our findings highlight the importance of sustained potassium management following discharge from immediate medical care, in order to avoid the burden of recurrent hyperkalaemia on patients and healthcare systems.
A number of limitations of this study are worth noting, and predominantly relate to the constraints of the data used to inform our analyses. The CPRD dataset may overestimate the incidence of hyperkalaemia due to pseudo-hyperkalaemia, a consequence of haemolysis following traumatic venepuncture, fist clenching during phlebotomy, blood sample contamination, inadequate blood sample storage, and delays between venepuncture and sample analysis [29]. Although causality cannot be inferred from this retrospective, observational database study, estimated IRRs for death, MACE and RAASi discontinuation were adjusted to account for confounding patient demographics, clinical histories and comorbidities, clinical measurements, and selected medication usage. Declining renal function was controlled for in our risk equations by including eGFR as a time-varying covariate; however, we acknowledge that related indices of kidney function (such as proteinuria) were not included in our analyses. Other candidate covariates were limited to those variables available within the CPRD; consequently, a number of unobserved or poorly-recorded potential confounders were not considered, such as socio-demographics, diet, lifestyle, ethnicity, smoking status, and the use of potassium-binding agents. Despite these limitations, the size of the CPRD dataset allowed this study to produce statistically-robust estimates of adverse event risk that verified the association curves observed across different geographical locations and comorbid populations.
In conclusion, this retrospective, observational cohort study sought to describe relationships between serum potassium levels and adverse clinical outcomes among CKD patients in UK clinical practice. Data arising from our analyses emphasise the importance of maintaining serum potassium levels within a narrow physiological range, in order to lower the risks of mortality, MACE and RAASi discontinuation. The risk equations derived represent a valuable tool to predict the incidence of adverse outcomes based on clinical characteristics; and identify CKD patients most likely to benefit from strategies that avoid hypo- and hyperkalaemia, enable optimal RAASi therapy, prevent RAASi discontinuation, and improve long-term outcomes.
Angiotensin-converting enzyme
ARB:
Angiotensin II receptor blocker
CI:
CPRD:
Clinical Practice Research Datalink
HES:
Hospital Episode Statistics
IRR:
Incident rate ratio
LOCF:
Last-observation-carried-forward
MACE:
Major adverse cardiac event
MRA:
Mineralocorticoid receptor antagonist
RAASi:
Renin-angiotensin-aldosterone system inhibitor
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Editorial assistance in the preparation of this manuscript was provided by Dr. Karina Hamilton and Dr. Daniel Sugrue of Health Economics and Outcomes Research Ltd. The authors also thank Dr. Susan Grandy and Dr. Klas Bergenheim of AstraZeneca, for their support and contribution to this work.
This study was supported by a grant from AstraZeneca. The funding agreement ensured the authors' independence in designing the study, interpreting the data, and preparing the manuscript for publication. EP and LQ are full-time employees of AstraZeneca, and were involved in the study conceptualisation and design, interpretation of results, and writing of the manuscript.
The datasets analysed in this study are available in the Clinical Practice Research Datalink (CPRD), https://www.cprd.com/home/.
Department of Nephrology, Uppsala University Hospital, Uppsala, Sweden
Hans Furuland
Health Economics and Outcomes Research Ltd, Cardiff, UK
Phil McEwan
, Daniel Ayoubkhani
& Hayley Bennett
School of Human and Health Sciences, Swansea University, Swansea, UK
Diabetes Resource Centre, University Hospital Llandough, Cardiff, UK
Marc Evans
Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
Cecilia Linde
Department of Cardiology, Royal Free Hospital, London, UK
Ameet Bakhai
Global Health Economics, AstraZeneca, Cambridge, UK
Eirini Palaka
Global Health Economics, AstraZeneca, 101 Orchard Ridge Drive, Gaithersburg, MD, 20878, USA
Lei Qin
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HF, ME, CL, AB, EP and LQ were involved in the study conceptualisation and design, interpretation of results, and writing of the manuscript. PM, DA and HB were involved in the study conceptualisation and design, data analysis, interpretation of results, and writing of the manuscript. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published.
Correspondence to Lei Qin.
Routinely collected, anonymised electronic health records from the Clinical Practice Research Datalink (CPRD) used as part of this study were provided by the Medicines and Healthcare Products Regulatory Agency (MHRA), an executive agency of the Department of Health & Social Care. This study was approved by the Independent Scientific Advisory Committee for MHRA database research on 15 December 2016 (study protocol 16_223R). Patient consent is covered by the CPRD privacy policy, available at https://www.cprd.com/home/. No other patient-level data were collected as part of this study.
HF has received modest research grant funding from AstraZeneca (as principal investigator), and modest expert witness funding from Amgen (as consultant). PM, DA and HB have received significant research grant funding from AstraZeneca in relation to this study. ME declares no conflict of interest. CL has received significant research grant funding from AstraZeneca (awarded to institution), and modest speaker honoraria from Biotronik, Medtronic, Abbot, Novartis and Vifor. AB has received modest advisory honoraria from AstraZeneca in relation to this study. EP and LQ are full-time employees of AstraZeneca.
Table S1. Read and International Classification of Diseases (ICD-10) codes used to define heart failure and chronic kidney disease. Example of the time-updating methodology used during data structuring. Table S2. Incidence of death, major adverse cardiac event and renin-angiotensin-aldosterone system inhibitor discontinuation observed in chronic kidney disease patients, stratified by serum potassium category. Table S3. Model output for final risk equations, re-estimated using patient-intervals restricted to a maximum duration of 30 days. (DOCX 58 kb)
Figure S1. Illustrative example of time-updated patient-intervals based on timing of serum potassium measurements. eGFR: estimated glomerular filtration rate; K+: serum potassium; MACE: major adverse cardiac event. (TIF 260 kb)
Figure S2. Validation of adjusted incident rate ratios for death (A) and MACE (B) as a function of serum potassium against those published by Luo et al. Black: estimated in the present study (UK CKD stage 3+ patients); grey: estimated by Luo et al. (US CKD stage 3+ patients). Error bars represent 95% confidence intervals. (TIFF 41 kb)
Figure S3. Adjusted incident rate ratios for death (A), MACE (B) and RAASi discontinuation (C) as a function of serum potassium in patients stratified by CKD stage. Black: CKD 3a patients; dark grey: CKD 3b patients; mid-grey: CKD 4 patients; light grey: CKD 5 patients. Incident rate ratios were adjusted to account for confounding patient demographics, clinical histories and comorbidities, clinical measurements, and medication usage, as reported in Table 4. CKD: chronic kidney disease; MACE: major adverse cardiac event; RAASi: renin-angiotensin-aldosterone system inhibitor. Error bars represent 95% confidence intervals. (TIFF 63 kb)
Hyperkalaemia
Serum potassium; chronic kidney disease
RAASi discontinuation


[QUOTE]Originally posted by sev8n: [b]Can anyone provide a link or reference?[/b][/QUOTE] The story has yet to be told online; it involves a number of players (including, in a not so insignificant way, collectSPACE). At some point, I plan to write an article.


The Exploration Committee of the Royal Society met yesterday afternoon, Sir William Stawell in the chair. There was a full attendance and the subject of the expedition was fully discussed. It was agreed that a special meeting should be convened for Thursday next, at 4 o'clock, when a leader will be chosen, subject to the approval of the Government. In the interval the testimonials of the different candidates will lie upon the table for examination. It is expected that the expedition will set out in six or seven weeks.
By private letter, we learn that the ship Suffolk, which was expected to sail from London on the 21st April last, would bring out 55 blackbirds and 25 thrushes, sent by Mr. Wilson to Dr. Mueller. A ship to sail in May would bring 100 linnets, and another sailing in June would convey 100 starlings, all sent by Mr. Wilson.
The camels were safely landed yesterday forenoon from the ship Chinsurah, and marched from the pier to the stables attached to the Houses of Parliament, where they are to be temporarily lodged. The camels marched in procession, each of the swifter kind with its turbaned rider on its back, picturesquely attired in white and red, followed by the burden-bearing animals, and the whole headed by Mr. Landells, in his Oriental costume, riding on his favourite camel. The line of route was by Sandridge-road, Prince's Bridge, Swanston-street, and Bourke-street, and large crowds lined the streets to see the novel procession. The streets were kept clear for the passage of the strangers by the police. The Scindian (Kurrachee) of the 31st March describes the camels as of the best description, and says:- "The camels which have been procured by Mr. Landells for the Victorian Government are of the finest description and the most hardy constitutions. Most of them have been procured from the Bickneer territory. This caste camel is well known as of large size and better constitution than those so easily procurable in Scinde, and Mr. Landells must have experienced many difficultie [sic] in obtaining them. They are certainly magnificent animals. This officer deserves great praise for his perseverance, while his success has been undoubted; the more so as his researches have been made at a time when the districts through which these had to be followed up were in a very unsettled state. Should fate be propitious, and these camels be safely landed on the shores of Australia, they will be the means of opening up a cast extent of country hitherto unknown, the Victorian Government having purchased these animals solely with the view of their being able with their means to penetrate further inland, and explore beyond former limits. Years hence, Australia will boast of its race of camels as England does now of her horse. The introducer or infuser of fresh blood, through whose instrumentality this desirable object was attained, will be hardly known, or if known at the present time, forgotten then; but from what great results may not be anticipated from this charter of the Chinsurah and the mission of Mr. Landells, in the large amount of territory opened up, with all of its vast resources; and the useful camel, with its noted endurance, indigenous, of form and size as famed as is their horse! We have not met Mr. Landells, but hear that he has gone beyond the mere limits of his mission, and that he has used his faculties to some purpose. He has picked up some specimens of the animal world in addition to the camel, that benefit the colony by importation. It is to be regretted that he has not been able to procure also two or three good high caste Arab stallions, and a Bagdadee mare or two. These would have been the nucleus of a race of horses indigenous to Australia, more famed than the now almost perfect English horse.


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The Kangaroo Joey enteral feeding pump allows formula to be infused in extremely accurate amounts (+/- 7%). It retains history for 72 hours, informing the user or caregiver of exactly how much formula has been dispensed over any given period of time. Memory settings can retain programmed data indefinitely, allow a feeding that has been stopped to resume.
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Weighing only 1.7 pounds, the compact Kangaroo Joey comes with a backpack for easy transport and inconspicuous use. Its long-life battery allows operation up to 18 hours (at 125 ml/hour). The Kangaroo Joey is quiet, water-resistant, shock-resistant and altitude-independent, making it extremely suitable for portable use.
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While economic conditions varied in 2017, most markets experienced at least modest growth which boosted hiring and led to candidate shortages in certain sectors. The most significant change was in Europe as the continent's economy and job market began to grow again following ten years of stagnation.
Want to know more? Request a copy of our Salary Survey today.


text:
InTranslation
Brooklynrail.org
Archive: El Salvador
Poetry by Claudia Lars
Written by Claudia Lars
Translated from the Spanish by Philip Pardi
El Salvador | Poetry | Spanish
Translator's Note:
Claudia Lars (pen name for Carmen Brannon Vega, 1899-1974) is one of El Salvador's most important and beloved poets. She is required reading in many Salvadoran schools, and several schools have been named in her honor. I first came to know her work in the 1990s, when I worked with a human rights organization in El Salvador: whenever I asked about poets, the reply included Lars, and I was delighted to discover that many of the Salvadorans I met had one or more of her poems memorized. As Stephen Tapscott notes, Lars was "a writer of integrity and continuity whose example and generosity toward younger writers, especially young woman poets, made her a beloved—and even symbolically maternal—figure in Latin American poetry."
Born to a Salvadoran mother and an Irish-American father, she was raised bilingual, and she learned French in Catholic school. Her youth was spent in the Salvadoran countryside reading Shakespeare, Jules Verne, and Lorca. She eventually translated a selection of Emily Dickinson's poetry into Spanish. Though she never traveled to Ireland, she retained a strong sense of connection to what she called "the land of my song." Her "two bloods" (as Gabriela Mistral writes in a famous letter) became an important theme in her work. Over the course of thirteen volumes of poetry, her poetics expand from an early reliance on the sonnet, ballad, and lira to uniquely-voiced explorations in free verse.
It feels important to bring Lars's work into English. Beyond the remarkable language and the many worlds brought into view, these poems offer a fresh glimpse of a country many of us in the United States think we know. El Salvador has long been in the news, at first because of the brutal civil war and later because of the U.N.-brokered ceasefire and elections. More recently, violence (in particular gang violence) has garnered headlines. Through it all, the U.S. has played a devastating and disproportionate role, whether by supporting the military governments of the 1980s or by deporting gang members in the years after the war. While such developments have kept the country in our sights, I have always felt that it is too easy to attend to the disasters. We should bear witness to them, certainly, and Lars herself takes note (in a poem like "Crumbs") as her country veers toward civil war. But the danger is that we let the catastrophes define the country and thereby narrow our sense of the world beyond our borders. What Lars's work offers is a glimpse of a woman's mind at work in the years before the tumultuous events of recent decades. Her concerns are worldly, spiritual, and lyrical; her verse offers the perspective of a poet who looks at the world around her—and into the future that is coming—with a longing and hopefulness that strike me as fundamentally and importantly human.
- Philip Pardi
Click Here To Read »
100 Refutations: Day 61
Written by Francisco Gavidia
Translated from the Spanish by Lina M. Ferreira C.-V.
100 Refutations | El Salvador | Poetry | Spanish
Francisco Gavidia (1863-1955) was a well-respected public figure in El Salvador known for his work as a writer, politician, lawyer, historian, educator, and journalist. His wide-ranging body of work includes everything from poetry and plays to music, pedagogy, and literary translation. In 1964, the Salvadoran government created a medal for intellectual merit named after Gavidia, to be awarded each year to a Central American writer or journalist who has made significant cultural contributions.
Written by Vicente Acosta
Vicente Acosta (1867-1908) was a Salvadoran poet, professor, and politician. He was widely published in Salvadoran journals and magazines, and in 1904 founded La Quincena, a journal of scientific and cultural studies.
Written by Susana Reyes
Susana Reyes earned a master's degree in Estudios de la Cultura Centroamericana with an emphasis in literature before working at several universities in El Salvador as a professor. She currently teaches at the Universidad Centroamericana José Simeón Cañas UCA. Reyes ran the now-defunct Escuela para Jóvenes Talento en Letras, a workshop for young writers; co-hosted the radio program La Bohemia on YSUK during the 1990s; and has participated in various theatrical productions, and led numerous theatrical workshops. She has also participated in investigations regarding the state of both literature at large and literature written by women in El Salvador. She is the literature editor of Índole Editores, belongs to the Grupo Literario Poesía y Más, serves as the current president of the Claribel Alegría Foundation, and directs the literary workshop Palabra y Obra.
Written by Krisma Mancía
Krisma Mancía was born in El Salvador in 1980. She has studied literature at the University of El Salvador, theater at La Escuela Arte del Actor, and sculpture and ceramics at the National Center of the Arts in El Salvador. She has also participated in the workshop La Casa del Escritor of El Salvador under the tutelage of Rafael Menjívar Ochoa. She is the author of La era del llanto, from Colección Nuevapalabra, published under the DPI imprint (Dirección de Publicaciones e Impresos); Viaje al Imperio de las Ventanas Cerradas, which was awarded first place in the international La Garúa prize for young poetry and was published in 2006 by La Garúa Press in Barcelona, Spain; Nueva Cosecha, with Editorial Casa de Poesía de Costa Rica; and Pájaros imaginarios y trenes invisibles entre tu ciudad y la mía, edited by Valparaíso de España and published by the Editorial Municipal de la Alcaldía de San Salvador. For more poetry and information, please visit https://krismatica.wordpress.com.
100 Refutations: Day 1
Written by Aída Párraga
Aída Párraga is a Salvadorean poet.
The Brooklyn Rail welcomes you to our web-exclusive section InTranslation, where we feature unpublished translations of fiction, nonfiction, poetry, and dramatic writing. Published since April 2007, InTranslation is a venue for outstanding work in translation and a resource for translators, authors, editors, and publishers seeking to collaborate.
We seek exceptional unpublished English translations from all languages.
Fiction, Nonfiction, and Poetry: Manuscripts of no longer than 20 pages (double-spaced).
Plays: Manuscripts of no longer than 30 pages (in left-justified format).
Please provide short biographies for the translator(s) and original author(s), 1-2 paragraphs in length. Translators who wish to have their contact information published should provide it.
Please provide a translator's note, no more than 500 words in length. The note may include critical analysis, historical contextualization, personal anecdote, or any other details the translator considers pertinent or interesting.
Translators must have obtained permission to publish from the copyright holder of the original work, unless it is in the public domain. Please provide copyright information (the name of the copyright holder + the year of original publication) for the original work.
Please submit all of your materials in a single MS Word document. Your email should include a short cover note introducing yourself and the work you're submitting.
All submissions and queries should be sent to [email protected].
91st Meridian
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text:
Amazon's Best Selling Author
L.D. CEDERGREEN
The Words We Leave Unspoken
At thirty-six, Gwen Porter has always done the right thing. A selfless pillar of strength, devoted wife and mother of two, she thrives on caring for those she loves. When Gwen learns a shattering, life-changing truth, her deepest concern is telling her husband, John. She finds herself on a destructive path of deceit and when her strength is tested, she turns to the most unlikely person.
For Charley Brant, Gwen's carefree, younger sister, life is about surviving another dead-end job or her next train-wreck relationship. She lives in the moment, denying herself any hope for a future. After years of relying on her sister's handouts and support, Charley finds herself in unfamiliar territory as she struggles to be the vessel of strength that Gwen needs to navigate through the storm.
As Gwen faces her darkest fear and an uncertain future, Charley turns to the past, unraveling secrets that will change everything that has come to define her. And in the wake of a tragedy, each will come to recognize that sometimes the most important words are the hardest ones to say.
After years of trying unsuccessfully to conceive a child, Gemma Walsh finds her husband in bed with another woman. Unable to face his betrayal, she retreats to Priest Lake where her family owns a small cabin. But Gemma finds that she is not the only one hiding away at the lake to avoid an ugly truth.
Andrew Monroe was once an essential part of Gemma's life but tragedy and misunderstanding shattered their bond, separating them. Now twenty years later, Gemma questions the coincidence of their newly intersected paths as she struggles to resist the sparks that ignite between them.
Just when Gemma feels that she has found her second chance at happiness, she is faced with a shocking truth as her reality spirals out of control. She can't deny the powerful force that brought Andrew back into her life anymore than she can defy the same force that now threatens to pull them apart.
An emotionally-charged, heart-rending story that will leave you to question the freedom in truth and the existence of fate in its deepest sense.
Kendall Brooks has an impossible decision: Tell the truth or protect the lie?
She has buried herself in years of undergrad, medical school, and now her residency–hoping to leave behind what she is unable to face.
Her world is rocked to the core when she returns to her small hometown and runs smack dab into her first love, Adam McCoy.
Adam is the key. He stirs up old emotions that send Kendall spiraling back in time, remembering all the moments that led them to her ultimate deception.
Will revealing the truth of what transpired all those years ago provide her the self-forgiveness that she desperately craves or will her devastating secret destroy the only man she has ever truly loved, shattering her heart in its wake?
© 2016 by L.D. Cedergreen.


text:
Q: Как проверить что в переменную передано null? Учу джавку, решаю ДЗ со skillbox.
Задание для теста :

Реализуйте метод sumDigits, который возвращает сумму цифр числа.
Пример: передано 12345, метод должен вернуть 15; если передано null, то должен вернуть -1.

Сделал подсчет суммы цифр, но не могу проверить на null.
public static int sumDigits(Integer number) {
    //@TODO: write code here and delete TODO line
    String string = Integer.toString(number);
    Integer sum = 0;
    if (number != null) {
      for (int i = 0; i < string.length(); i++) {
        sum += Integer.parseInt(String.valueOf(string.charAt(i)));
      }
      return sum;
    }
     else {
     return -1;
    }
}

как правильно?

A: вот что значит учится ночью )
я в тесте получал npe
вот и не проверяло на нулл
сначала проверим обЪект на нулл, а потом с ним работаем, а я наоборот сделал
вот правильно как :
  Integer sum = 0;
if (number != null) {
  String string = Integer.toString(number);
  for (int i = 0; i < string.length(); i++) {
    sum += Integer.parseInt(String.valueOf(string.charAt(i)));
  }
  return sum;
}
 else {
 return -1;
}

A: Вот так будет правильней, без конвертации в строку и обратно и c использованием примитивного int.
public static int sumDigits(int number) {
    if (number == null) {
        return -1;
    }
    int sum = 0;
    while (number > 0) {
        int remain = number % 10;
        sum += remain;
        number = (number - remain) / 10;
    }
    return sum;
}

redpajama_set_name: RedPajamaStackExchange


What if Australia had negative interest rates?
What would happen if we had negative interest rates?
What would happen if Australia had negative interest rates? Is that even possible, I hear many of you ask?
Wouldn't that mean we'd be paying the bank to look after our deposits? What sort of fool would do that?
But that's exactly what has been happening in Europe where the European Central Bank has been "charging" commercial banks to hold their deposits since mid-2014. Negative interest rates have also been introduced in Japan, Sweden, Switzerland and Denmark.
In a weak economy, negative interest rates can be seen as a way to discourage people from hoarding their money.
If they have to pay for the privilege of holding cash in a bank, the theory goes, they'd be better off spending or investing instead.
Or, in the case of banks, they'd be better off lending the money to consumers and businesses rather than keeping it in the central bank. So in that sense, negative interest rates can be a way to kickstart economic activity.
They are also seen as a way to fire inflation in economies where deflation – or falling prices – has become a problem.
The other effect of negative interest rates – and for some central banks this is just as important, or even more so – is that they can take pressure off a country's currency, making it more competitive on international markets. After all, who would want to invest in a currency that actually costs them money?
It's unexplored territory and the jury is out. Banks have been reluctant to pass on negative rates to customers, limiting the impact. In an April paper, the International Monetary Fund (IMF) gave qualified support to the policy, saying they should support demand and price stability. But it warned there were limits to how far and for how long negative rates could go.
Critics have pointed out that negative rates can push investors from safe assets, such as bonds and cash, into riskier assets as they chase returns, potentially creating asset bubbles. They also argue that credit availability for lending is not the problem in most economies.
People are already in debt, and they are uncertain about the future, so they are reluctant to borrow more, limiting the effectiveness of negative rates.
Because banks are effectively being taxed to hold money with the central bank, and are not passing negative rates onto depositors, bank margins are also being squeezed, potentially making them unwilling to lend.
The one thing that can be said for certain is that negative rates are not good. They are a sign of economic uncertainty, and that alone is likely to limit their effectiveness.
What would negative rates mean for people like me?
Let's start with the good news. Interest rates in Australia are still positive in both real and nominal terms. But, as with much of the rest of the world, rates are at historically low levels. The April Reserve Bank cash rate of 2% was just 0.3% above the inflation rate of 1.7%, giving savers a paltry return on their money after inflation.
A 35-year old wanting a $48,000 income in retirement at 65 would need to invest $178,000 today at a 5% interest rate but more than three times that amount – $563,000 – at 2%.
Negative rates could actually have the opposite effect to what was intended by forcing people to cut spending to save more for retirement, and forcing retirees to spend less as they have a reduced income.
As the overseas experience has shown, banks are reluctant to pass on negative rates to consumers for fear of creating a customer rush into holding cash. There have been reports already that safe sales are increasing in countries, including in Germany.
But nor has there been a widespread move to rewarding borrowers. In fact, some borrowers' costs have gone up through higher fees and other charges as lenders attempt to recoup some losses.
With Australia's economy still heavily dependent on what happens in China, its economic growth – or lack thereof – will play an important role in our future.
When all these low (or negative) interest rates finally have the intended effect, namely to change the public's perception of the financial situation, resulting in increased confidence and spending, it will be impossible to halt the avalanche. As the psychology of entire economies (nations) switches they won't be able to raise interest rates fast enough to stop the spending in time, which is likely to result in runaway hyper-inflation. Capitalism may have run it's course, as the currency that underpins the world's financial markets, and has had a monopoly on oil purchasing (USD,) was de-coupled from physical gold reserves decades ago. Given much of US national and household debt is held overseas, there seems to be only ever-increasing odds that this will come home to roost and the effects will be catastrophic. Money, why don't you do a piece on the effects of fiat currency creation being controlled by private entities across the globe?


It seems that every New England resident has visited, skied, or snowboarded at one of the dozens of available resorts. Though this is true for many Connecticut residents, the state significantly lacks resources. Low in resorts, shops, and community organizations, Connecticut residents—especially those in the eastern part of the state—must actively seek alpine opportunities to pursue the sport. With such a shortage of outlets, why haven't Connecticut residents pooled their resources? Well, that's what we're here to do.
The New Haven Ski Club is a place for eastern Connecticut residents to share resources, organize trips, and meet others. Think of it as a virtual meeting place and font of New England knowledge. We, the club's founders, will post blogs and general knowledge resources about Connecticut resorts, stores, and opportunities, but this should serve, first and foremost, as a forum for people seeking resources.