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Objective: To examine the renoprotective effects of metabolic surgery in patients with established chronic kidney disease (CKD). Background: The impact of metabolic surgery compared with glucagon-like peptide-1 receptor agonists (GLP-1RA) in patients with established CKD has not been fully characterized. Methods: Patients with obesity (body mass index =30 kg/m²), type 2 diabetes, and baseline estimated glomerular filtration rate (eGFR) 20-60 mL/min/1.73 m² who underwent metabolic bariatric surgery at a large US health system (2010-2017) were compared with nonsurgical patients who continuously received GLP-1RA. The primary end point was CKD progression, defined as a decline of eGFR by =50% or to <15 mL/min/1.73 m2, initiation of dialysis, or kidney transplant. The secondary end point was the incident kidney failure (eGFR <15 mL/min/1.73 m2, dialysis, or kidney transplant) or all-cause mortality. Results: 425 patients, including 183 patients in the metabolic surgery group and 242 patients in the GLP-1RA group, with a median follow-up of 5.8 years (IQR, 4.4-7.6), were analyzed. The cumulative incidence of the primary end point at 8 years was 21.7% (95% CI: 12.2-30.6) in the surgical group and 45.1% (95% CI: 27.7 to 58.4) in the nonsurgical group, with an adjusted hazard ratio of 0.40 (95% CI: 0.21 to 0.76), P=0.006. The cumulative incidence of the secondary composite end point at 8 years was 24.0% (95% CI: 14.1 to 33.2) in the surgical group and 43.8% (95% CI: 28.1 to 56.1) in the nonsurgical group, with an adjusted HR of 0.56 (95% CI: 0.31 to 0.99), P= 0.048. Conclusions: Among patients with type 2 diabetes, obesity, and established CKD, metabolic surgery, compared with GLP-1RA, was significantly associated with a 60% lower risk of progression of kidney impairment and a 44% lower risk of kidney failure or death. Metabolic surgery should be considered as a therapeutic option for patients with CKD and obesity. [ABSTRACT FROM AUTHOR]

Patients with metabolic syndrome (MetS) have a higher risk for NASH and significant fibrosis. Presence of NASH and advanced fibrosis are associated with adverse outcomes in patients with NAFLD. Using a noninvasive method, we determined the prevalence of at-risk NASH and its association with MetS components in a large population-based analysis. We used the 2017-2018 National Health and Nutrition Examination Survey and included adults = 18 years with NAFLD (controlled attenuation parameter =274 dB/m). Pregnancy, subjects with other causes of liver disease or missing data were excluded. FibroScan-AST (FAST) score was calculated using aspartate aminotransferase, liver stiffness measurement, and controlled attenuation parameter. Patients with a FAST score >0.35 were considered to have at-risk NASH, defined as NASH with NAFLD activity score = 4 and fibrosis stage =2 on liver biopsy. The sample included 687 patients. The overall prevalence of at-risk NASH was 11.6% (95% CI: 8.8-15.1) and was higher in males than females (15.8% vs. 6.5%; p < 0.001). Subjects with comorbidities (diabetes mellitus, obesity, MetS, and insulin resistance) had between 1.3 and 1.7 times higher prevalence than the general population. Among MetS components, elevated glucose/diabetes, large waist circumference, and low HDL were independent risk factors for at risk-NASH. The number of MetS components was also important--one additional component increased the odds of at-risk NASH by 2 times. The FAST score had the highest correlation with alanine aminotransferase (r= 0.70; p < 0.001). We estimated ~9 million people in the US have at-risk NASH and may benefit from active surveillance and therapy. [ABSTRACT FROM AUTHOR]

Objectives: Opioid receipt during medical hospitalizations may be associated with subsequent long-term use. Studies, however, have not accounted for pain, which may explain chronic use. The objective of this study was to identify the association between opioid exposure during a medical hospitalization and use 6 to 12 months later.Methods: This was an observational cohort study using electronic health record data from 10 hospitals in the Cleveland Clinic Health System in 2016. Eligible patients were opioid-naïve adults with pain age 18 years and older, admitted to a medical service. Outcomes were opioid receipt during hospitalization and on discharge, and long-term opioid use, defined as ≥2 prescriptions for at least 30 pills 6 to 12 months posthospitalization. We estimated the odds of long-term opioid use by opioid exposure during the hospitalization. Models controlled for patient demographic and clinical characteristics, including patient-reported pain.Results: Among the 2971 patients in the sample, 64% received opioids during their hospitalization and 28% were discharged with opioids. Overall, 3% of patients had long-term use. Higher pain score was associated with greater odds of long-term use (adjusted odds ratio [aOR] per point increase 1.11; 95% confidence interval [CI] 1.03-1.19). No patient factors were associated with long-term use. Receipt of an opioid during a hospitalization only was not associated with long-term use (aOR 1.44, 95% CI 0.81-2.57), but receipt at discharge was (aOR 1.96, 95% CI 1.08-3.56).Conclusions: Although opioid receipt at discharge was associated with long-term use, the number of patients this applied to was small. Pain severity was an important predictor of long-term use and should be accounted for in future studies. [ABSTRACT FROM AUTHOR]

The objective of the study was to assess the association between care quality of skilled nursing facilities (SNFs) and 30-day risk-adjusted readmission rate (RAR) for patients with acute decompensated heart failure (ADHF). A retrospective cohort study was conducted involving 603 discharges from a tertiary care hospital to 17 SNFs after hospitalization for ADHF. SNF quality was assessed based on the CMS 5-star quality rating and a survey of SNF characteristics and processes of care. In all, 20% of cases were readmitted within 30-days; 9.4% were for ADHF. The all-cause RARs for higher- and lower-quality SNFs were 18% (95% confidence interval [CI] = 14%-23%) and 22% (95% CI = 17%-26%), respectively, and the ADHF RARs were 8.8% (95% CI = 6.0%-11.6%) and 10.2% (95% CI = 7.0%-12.9%), respectively. There were no significant associations between ADHF RARs and individual processes of care or structural characteristics. Quality ratings of SNF or processes of care did not correlate with RAR. [ABSTRACT FROM PUBLISHER]

The article discusses some misconceptions with regards to coronary artery disease. It cites the model of an obstructed pipe which is accurate in the setting of myocardial infarction where interventions to eliminate the thrombus can be lifesaving but for patients with stable disease local interventions can only relieve symptoms. It cites the plumbing model that perpetuates misconceptions on fat consumption. It suggests for better models as a means to more patient-centered, cost-effective care.

The article provides information on a study which examined changes in the incidence, number of hospitalization, outcomes and costs of hospitalization for severe and nonsevere sepsis in the U.S. from 2003 to 2007. The study focused on the changes in occurrence of specific organ dysfunctions, the impact of changes in coding and documentation and changes in costs of care over time. The weighted frequency of patients hospitalized with severe sepsis was determined.

The article presents a study that compares the outcomes of patients with septic shock who received early treatment with activated protein C to those who did not. It observes a similar pattern across groups stratified by age and number of organ-supportive therapies. It found 0.25% of treated patients have hemorrhagic stroke and 6.8% have gastrointestinal bleeding. Moreover, it suggests that early treatment with activated protein C may reduce hospital mortality.

Background: Responding to research confirming the link between nurse staffing and patient outcomes, 14 states have introduced legislation to limit patient-to-nurse ratios. However, increased staffing places a considerable financial burden on hospitals.Objective: We sought to determine the cost-effectiveness of various nurse staffing ratios.Research Design: This was a cost-effectiveness analysis from the institutional perspective comparing patient-to-nurse ratios ranging from 8:1 to 4:1. Cost estimates were drawn from the medical literature and the Bureau of Labor Statistics. Patient mortality and length of stay data for different ratios were based on 2 large hospital level studies. Incremental cost-effectiveness was calculated for each ratio and sensitivity and Monte Carlo analyses performed.Subjects: The study included general medical and surgical patients.Measures: : We sought to measure costs per life saved in 2003 US dollars. RESULTS OF BASE CASE ANALYSIS: Eight patients per nurse was the least expensive ratio but was associated with the highest patient mortality. Decreasing the number of patients per nurse improved mortality and increased costs, becoming progressively less cost-effective as the ratio declined from 8:1 to 4:1. Nonetheless, the incremental cost-effectiveness did not exceed US dollars 136,000 (95% CI US dollars 53,000-402,000) per life saved.Results Of Sensitivity Analysis: The model was most sensitive to the effects of patient-to-nurse ratios on mortality. Lower ratios were most cost-effective when lower ratios shortened length of stay, and hourly wages were low. However, throughout the ranges of all these variables, the incremental cost-effectiveness of limiting the ratio to 4:1 never exceeded US dollars 449,000 per life saved.Conclusions: As a patient safety intervention, patient-to-nurse ratios of 4:1 are reasonably cost-effective and in the range of other commonly accepted interventions. [ABSTRACT FROM AUTHOR]

Background: There are multiple risk assessment models (RAMs) for venous thromboembolism prophylaxis, but it is unknown whether they increase appropriate prophylaxis., Methods: To determine the impact of a RAM embedded in the electronic health record, we conducted a stepped-wedge hospital-level cluster-randomized trial conducted from October 1, 2017 to February 28, 2019 at 10 Cleveland Clinic hospitals. We included consecutive general medical patients aged 18 years or older. Patients were excluded if they had a contraindication to prophylaxis, including anticoagulation for another condition, acute bleeding, or comfort-only care. A RAM was embedded in the general admission order set and physicians were encouraged to use it. The decisions to use the RAM and act on the results were reserved to the treating physician. The primary outcome was the percentage of patients receiving appropriate prophylaxis (high-risk patients with pharmacological thromboprophylaxis plus low-risk patients without prophylaxis) within 48 hours of hospitalization. Secondary outcomes included total patients receiving prophylaxis, venous thromboembolism among high-risk patients at 14 and 45 days, major bleeding, heparin-induced thrombocytopenia, and length of stay. Mixed-effects models were used to analyze the study outcomes., Results: A total of 26 506 patients (mean age, 61; 52% female; 73% White) were analyzed, including 11 134 before and 15 406 after implementation of the RAM. After implementation, the RAM was used for 24% of patients, and the percentage of patients receiving appropriate prophylaxis increased from 43.1% to 48.8% (adjusted odds ratio, 1.11 [1.00-1.23]), while overall prophylaxis use decreased from 73.5% to 65.2% (adjusted odds ratio, 0.87 [0.78-0.97]). Rates of venous thromboembolism among high-risk patients (adjusted odds ratio, 0.72 [0.38-1.36]), rates of bleeding and heparin-induced thrombocytopenia (adjusted odds ratio, 0.19 [0.02-1.47]), and length of stay were unchanged., Conclusions: Implementation of a RAM for venous thromboembolism increased appropriate prophylaxis use, but the RAM was used for a minority of patients., Registration: URL: https://www.clinicaltrials.gov/study/NCT03243708?term=nct03243708&rank=1; Unique identifier: NCT03243708.

Influenza is a seasonal viral infection associated with significant morbidity and mortality. In 2009, a novel H1N1 influenza A virus emerged and has been classified as a pandemic. In contrast to seasonal influenza, severe disease from pandemic H1N1 seems concentrated in older children and young adults, with almost no cases reported in patients older than 60 yrs. Although patients with underlying cardiopulmonary disease remain at risk, most complications have occurred among previously healthy individuals, with obesity and respiratory disease as the strongest risk factors. Pulmonary complications are common. Primary influenza pneumonia occurs most commonly in adults and may progress rapidly to acute lung injury requiring mechanical ventilation. Secondary bacterial infection is more common in children. Staphylococcus aureus, including methicillin-resistant strains, is an important cause of secondary bacterial pneumonia with a high mortality rate. Treatment of pneumonia should include empirical coverage for this pathogen. Neuromuscular and cardiac complications are unusual but may occur.