Early access flow rate predicts vascular access patency-related intervention in the first year: A retrospective cohort study.

INTRODUCTION: Arteriovenous fistulas and grafts are lifelines for most hemodialysis patients, and a low access flow rate often requires patency-related intervention, such as angioplasty or thrombectomy, to prevent access failure. We examined whether early access flow rate, measured after initial fistula/graft cannulation, predicts vascular access patency-related intervention within 1 year. METHODS: This was a single-center retrospective cohort study. Among 172 patients undergoing surgical creation of a fistula/graft, 52 (30.2%) had documented access flow rates measurement by the Transonic™ ultrasound dilution technique, performed within an average of 48 days from initial access cannulation. The need for a patency-related intervention, defined as undergoing a fistulogram, angioplasty, thrombectomy, or surgical revision, was ascertained within 1 year. A receiver-operating characteristic curve (ROC) was generated to evaluate the diagnostic performance of first and average access flow rates for predicting patency-related intervention within 1 year. FINDINGS: Twenty-eight (53.8%) of the 52 study subjects required a patency-related intervention within 1 year. Their characteristics were not significantly different from those who did not require patency-related interventions. However, first access flow rates were significantly lower in patients requiring patency-related intervention compared to those who did not (898 vs. 1471 mL/min; p = 0.003), as were average access flow rates (841 vs. 1506 mL/min; p < 0.001). The ROC analyses revealed that first access flow rates and average access flow rates predicted the need for patency-related intervention within 1 year, with an area under-the-ROC curve of 0.743 (95% confidence interval [CI] 0.608, 0.877) and 0.775 (95% CI 0.648, 0.903), respectively, demonstrating acceptable discrimination. DISCUSSION: In adults undergoing hemodialysis, early access flow rate measurement can predict patency-related intervention within 1 year after initial vascular access cannulation. Additional studies are required to confirm these findings and identify optimal access flow rate cut-off values to predict vascular accesses at higher risk of stenosis.

Association of Body Mass Index with Multiple Organ Failure in Hospitalized Patients with COVID-19: A Multicenter Retrospective Cohort Study.

Purpose: This study examines whether excessive adipose tissue, as measured by the body mass index (BMI), is associated with higher systemic markers of inflammation and higher risk of severe acute organ failure among patients with coronavirus disease 2019 (COVID-19). Methods: This was a multicenter retrospective cohort study of 1370 hospitalized adults (18 years or older) with COVID-19 during the first wave of the pandemic. Patient-level variables were extracted from the electronic medical record. The primary predictor variable was the BMI at time of hospital admission, in accordance with the World Health Organization classification. Multivariable logistic regression analyses examined the association of BMI with the composite of acute respiratory distress syndrome (ARDS), as defined by the use of high-flow nasal canula, non-invasive ventilation, or mechanical ventilation, severe acute kidney injury (AKI), as defined by acute dialysis requirement, or in-hospital death. Results: After adjustment for important cofounders, the BMI stratum of > 40 kg/m2 (compared to the BMI < 25 kg/m2 reference group) was associated with higher odds for the composite of ARDS, severe AKI, or in-hospital death (adjusted odds ratio [ORadj] 1.69; 95% confidence interval [CI]1.03, 2.78). As a continuous variable, BMI (per 5-kg/m2 increase) remained independently associated with the composite outcome (ORadj 1.13; 95% CI 1.03, 1.23); patients in higher BMI categories exhibited significantly higher peak levels of C-reactive protein (CRP), a systemic marker of inflammation (P = .01). In a sub-cohort of 889 patients, the association of BMI with the composite outcome was no longer significant after adjustment for the peak level of CRP. Conclusions: Among hospitalized patients with COVID-19, a higher BMI is associated with higher risk of severe organ failure or in-hospital death, which dissipates after adjustment for CRP level. This supports the hypothesis that inflammation is a downstream mediator of adipose tissue on acute organ dysfunction.

Association of Serum Free Light Chain Level with Long-Term Kidney Function in Patients with Newly Diagnosed Multiple Myeloma.

INTRODUCTION: Multiple myeloma (MM) frequently involves the kidneys, resulting in acute, subacute, or chronic kidney disease (CKD). Patient- and treatment-related factors are associated with the long-term development of CKD. The aim of our study was to examine the association of serum free light chain (FLC) levels, measured at the time of diagnosis of MM, and CKD at subsequent follow-up. METHODS: Patients with newly diagnosed MM were identified using cancer registries at five hospitals. The primary outcome was low eGFR (<60 mL/min/1.73 m2) or dialysis dependence and a secondary composite outcome of low eGFR, dialysis dependence, or death at the last follow-up, up to 12 months from diagnosis. Logistic regression analyses were performed. RESULTS: A total of 149 patients met the inclusion criteria. Patients with an FLC level above the median had a higher frequency of hypertension (54% vs. 81%; p < 0.001), hyperlipidemia (37% vs. 56%; p = 0.018), low eGFR at the time of diagnosis (43% vs. 66%; p = 0.006), and a higher MM stage (p = 0.018). On multivariable analyses, after adjustment for several covariates, serum FLC level (per each 100 mg/L) was independently associated with low eGFR or dialysis dependence at follow-up (adjusted odds ratio [aOR] 1.021; 95% CI: 1.002, 1.041; p = 0.033). This association persisted for the composite outcome of low eGFR, dialysis dependence, or death (aOR 1.034; 95% CI: 1.006, 1.063; p = 0.018). DISCUSSION/CONCLUSION: Higher serum FLC level measured at the time of MM diagnosis is independently associated with CKD at up to 12 months of follow-up.

Implementation of a palliative care consultation trigger tool for hospitalised patients with acute decompensated heart failure.

Heart failure is a leading cause of hospitalisations. Integration of palliative care services with medical therapy in the management of hospitalised patients with heart failure is imperative. Unfortunately, there are no standardised criteria for palliative care referrals among hospitalised patients with acute decompensated heart failure. The objective of our quality improvement project was to develop and implement a palliative care consult trigger tool for hospitalised patients with acute decompensated heart failure. We found that among eligible patients, palliative care referrals were underused, likely contributing to misalignment of goals of care and suboptimal advance care planning. We developed a trigger tool and designed and implemented structured multicomponent educational interventions to improve the appropriateness and timeliness of inpatient palliative care consultations in this high-risk population. The educational interventions led to a significant increase in the rate of appropriate inpatient palliative care consultations among hospitalised patients with acute decompensated heart failure (46.3% vs 27.7%; p=0.02). In addition, palliative care referrals resulted in better alignment of goals of care at the time of hospital discharge, as measured by a significant increase in the completion rate of a healthcare proxy form (11.4% vs 47.2%; p<0.001) and a Medical Order for Life-Sustaining Treatment form (2.0% vs 24.1%; p<0.001), as well as the establishment of a Do-Not-Resuscitate order (2.7% vs 29.6%; p<0.001). Furthermore, the intervention resulted in a significant decrease in the hospital readmission rate up to 90 days post-discharge (43.6% vs 8.3%; p<0.001). This quality improvement project calls for the development and adoption of standardised criteria for palliative care referrals to benefit hospitalised patients with heart failure and reduce symptom burden, align goals of care and improve quality of life.

Acute on chronic bilateral renal vein thrombosis in the setting of remission of class V lupus nephritis: A case report and literature review.

Renal vein thrombosis (RVT), defined as the presence of a thrombus in the major renal vein or one of its tributaries, can present acutely or go unnoticed resulting in acute kidney injury or chronic kidney disease. RVT is associated with multiple etiologies, including nephrotic syndrome, thrombophilia, autoimmune disorders, and malignancy. Patients with systemic lupus erythematosus (SLE), a multiorgan autoimmune disorder, are predisposed to coagulopathy and thus are at a higher risk of venous and arterial thromboembolism. We describe the case of a 41-year-old man with SLE and biopsy-proven membranous glomerulonephritis (WHO class V lupus nephritis) in clinical remission with no evidence of nephrotic range proteinuria who presented with macroscopic hematuria and was diagnosed with acute-on-chronic bilateral RVT. We discuss the different causes of RVT and compare the clinical presentation, diagnostic imaging findings, and management of acute and chronic RVT.

Cerebral venous thrombosis in an adult with relapsing minimal change disease.

Minimal change disease (MCD) is a well-known cause of fulminant acute nephrotic syndrome (NS) and has been associated with thrombotic complications. We report the case of a 51-year-old woman with previous biopsy-proven MCD in remission who presented with worsening headache and acute confusion shortly after a relapse of the NS and was diagnosed with cerebral venous thrombosis (CVT) complicated by intracranial hemorrhage and midline shift. One month prior, she had been initiated on an oral contraceptive agent during remission of the NS. After initiation of systemic anticoagulation, her condition rapidly deteriorated, and she passed away before being able to undergo catheter-based venous thrombectomy. We conducted a systematic literature review and identified 33 case reports of adults with NS-associated CVT. The most common symptoms were headache (83%), nausea or vomiting (47%), and altered mental status (30%). 64% of patients presented at time of initial diagnosis of the NS and 32% during a relapse. Mean urinary protein excretion was 9.32 g/day and mean serum albumin was 1.8 g/dL. 91% of patients received systemic anticoagulation, and 19% died. The outcome in the remaining cases was favorable with only one report (5%) of residual neurological deficit. Of the available kidney biopsy results, MCD was the most common diagnosis (70%), raising the hypothesis that the fulminant acute onset of the NS might be a predisposing factor for this serious thrombotic complication. Clinicians should have a high index of suspicion for CVT in patients with the NS who present with new-onset neurological symptoms, including headache and nausea.

Improving compliance with appropriateness of testing for heparin-induced thrombocytopaenia: a quality improvement report.

Heparin-induced thrombocytopaenia (HIT) is a serious complication of heparin therapy. Evidence-based guidelines recommend the use of the 4Ts scoring system to calculate pretest probability of HIT. However, this scoring system is often underused, and inappropriate testing can lead to increased morbidity, medical costs and length of hospital stay. We identified that inappropriate testing for HIT was common at our institution and implemented structured multicomponent educational interventions to evaluate the impact of education on the appropriateness of HIT testing. The educational interventions led to a significantly increased rate of appropriateness of HIT testing (69% vs 35%; p=0.001). In addition, the 4Ts score documentation rate significantly improved following the intervention (52% vs 17%; p=0.001). The rates of discontinuation of heparin products and initiation of alternative anticoagulation increased, although not statistically significantly. Educational interventions can improve compliance with evidence-based guidelines on appropriateness of testing for HIT.

Factors Associated with Severity of Acute Kidney Injury and Adverse Outcomes in Critically Ill Patients with COVID-19.

BACKGROUND: Acute kidney injury (AKI) is a well-recognized complication of coronavirus disease 2019 (COVID-19). The short and long-term outcomes of patients who develop AKI have not been well characterized. METHODS: In this multicenter retrospective cohort study, we describe the clinical characteristics and outcomes of critically ill adults with severe COVID-19 and AKI. Patient-level variables were extracted from the electronic medical record. Using nadir-to-peak serum creatinine, AKI was defined using the KDIGO definition. Multivariable logistic regression analyses examined factors associated with development of moderate-to-severe (stage 2-3) AKI, severe (stage-3) AKI, and the composite of renal replacement therapy (RRT) or in-hospital death. RESULTS: Among 459 critically ill adults with COVID-19, 371 (80.1%) developed AKI, with 179 (37.9%) developing stage-3 AKI. Male gender, black and Asian/Native American race, lower baseline estimated glomerular filtration rate (eGFR), higher body mass index (BMI), and higher Acute Physiology and Chronic Health Evaluation (APACHE) IV score were more prevalent among patients with severe AKI, as were systemic markers of inflammation. On multivariable analysis, male gender, black and Asian/Native American race, higher APACHE IV score, lower baseline eGFR, and higher BMI (mainly the highest BMI stratum ≥35 kg/m2) were independently associated with higher stages of AKI severity. Male gender, lower baseline eGFR, and higher APACHE IV score were also independently associated with the composite of RRT or in-hospital death. Moderate-to-severe AKI and severe AKI were independently associated with in-hospital death, and there was a significant interaction between BMI and moderate-to-severe AKI for the outcome of in-hospital death. Among 83 (18.1%) patients who required RRT, 27 (32.5%) survived, and 12 (44.4%) remained dialysis-dependent at discharge. At 3 and 6 months, 5 (41.7%) and 4 (33.3%) remained dialysis-dependent, respectively. CONCLUSIONS: AKI is common in critically ill adults with COVID-19. Several patient-level risk factors are associated with higher stages of AKI severity. BMI might be an effect modifier of AKI severity for in-hospital death. Among AKI survivors, there is a high rate of short- and long-term dialysis dependence.

Country-level determinants of COVID-19 case rates and death rates: An ecological study.

The Coronavirus Disease 2019 (COVID-19) pandemic has had a variable worldwide impact, likely related to country-level characteristics. In this ecological study, we explored the association of COVID-19 case rates (per 100,000 people) and death rates (per 100,000 people) with country-level population health characteristics, economic and human development indicators, and habitat-related variables. To calculate country-level COVID-19 case and death rates, the number of cases and deaths were extracted from the Johns Hopkins Coronavirus Resource Center through September 30, 2021. Country-level population health characteristics, economic, human development, and habitat-related indicators were extracted from several publicly available online sources of international organizations. Results were tabulated according to world zones and country economies. Unadjusted and adjusted multiple imputation linear regression analyses were performed to examine the association between country-level variables (per 1-standard deviation [SD] increase) and COVID-19 case and death rates. To satisfy the linear regression model assumptions of normality of residuals, we used the square root transformation of both outcomes. A total of 187 countries and territories were analyzed, with a median (25th, 75th percentiles) aggregate COVID-19 case rate of 3,605 (463, 8,228) per 100,000, a COVID-19 death rate of 45.9 (8.9, 137.1) per 100,000, and a case-fatality rate of 1.6% (1.2%, 2.6%). On multivariable analyses, each country-level 1-SD higher percentage of adults with obesity (ß coefficient 13.7; 95% confidence interval [CI] 13.7; 8.9, 18.4), percentage of smokers (5.8; 95% CI 1.2, 10.5), percentage of adults with high blood pressure (4.9; 95% CI 0.3, 9.6), and gross national income (GNI) per capita (9.5; 95% CI 4.6, 14.5) was independently associated with higher square root of COVID-19 case rate, while average household size (-1.7; 95% CI -12.3, -3.2) was independently associated with lower square root of COVID-19 case rate. Similarly, each 1-SD higher percentage of adults with obesity (1.76; 95% CI 0.99, 2.52), percentage of adults with high blood pressure (1.11; 95% CI 0.48, 1.74), percentage of adults with physical inactivity (1.01; 95% CI 0.10, 1.191), and travel & tourism competitiveness index (1.05; 95% CI 0.06, 2.04) was independently associated with higher square root of COVID-19 death rate, whereas GNI per capita (-0.92; 95% CI -1.81, -0.03), and average household size (-1.07; 95% CI -1.87, -0.27) was independently associated with lower square root of COVID-19 death rate. This ecological study informs the need to develop country-specific public health interventions to better target populations at high risk for COVID-19, and test interventions to prevent transmission of SARS-CoV-2, taking into consideration cross-country differences in population health characteristics, and economic, human development and habitat-related factors.

Recent Trends in Infective Endocarditis Among Patients with and Without Injection Drug Use: An Eight-Year Single Center Study.

BACKGROUND: Infective endocarditis (IE) is associated with considerable morbidity and mortality. Given the opioid crisis and emergence of drug-resistant organisms, we sought to examine annual trends in hospitalization rates for IE and potential epidemiologic shift in the causative microorganisms among patients with and without injection drug use (IDU). METHODS: This was a single-center retrospective cohort study of hospitalized adults with IE. Annual trends in hospitalization rates were calculated (2011-2018), and patient characteristics and clinical outcomes were compared according to IDU status. RESULTS: Our cohort of 244 hospitalized patients with IE had a subset of 112 with IDU. The annual hospitalization rate for IE increased almost four-fold and was most notable among patients with IDU. The highest increase occurred in patients with Staphylococcus aureus-associated IE. Patients with IDU were younger, and more likely to be women with tricuspid valve vegetations and have IE due to methicillin-sensitive and methicillin-resistant Staphylococcus aureus. Patients without IDU were more likely to have central venous catheters with mitral and aortic valve vegetations and have IE due to Streptococcus and coagulase-negative Staphylococcus species. Patients without IDU had a higher requirement for cardiac surgery and higher 90-day mortality. Age was the only independent variable associated with 90-day mortality. CONCLUSIONS: The rising incidence of IE in younger and older persons is driven in part by the opioid public health crisis and higher prevalence of indwelling central venous catheters, respectively. Timely treatment of opioid use disorders and stewardship surrounding use of central venous catheters is urgently needed.

Hospital-acquired acute kidney injury: a proposed patient safety indicator.

Patient safety, which includes adverse event reporting and routine collection of outcome measures, has become an increasingly important aspect of inpatient care worldwide. In the United States, the National Quality Forum leads the effort in developing such measures for use in payment and public reporting programs. However, choosing and prioritizing events to serve as patient safety indicators is difficult in a dynamically changing and complex healthcare environment. In this perspective, we propose that hospital-acquired acute kidney injury (HA-AKI), for example, contrast-induced and postoperative AKI, should be added to existing, more traditional measures, such as surgical site infections and patient falls. The article highlights the significance of HA-AKI as a common complication resulting from a multitude of diagnostic and therapeutic procedures, how it lends itself well to measuring patient safety, and how reporting of this complication can contribute to further improvement of patient safety and overall quality of care.

Revising the Maximal Contrast Dose for Predicting Acute Kidney Injury following Coronary Intervention.

INTRODUCTION: The maximal allowable contrast dose (MACD = 5 × body weight/serum creatinine) is an empiric equation that has been used and validated in several studies to mitigate the risk of contrast-induced acute kidney injury (CI-AKI). However, coefficient 5 (referred to as factor K) was empirically devised and never disputed. The aim of this study was to refine the MACD equation for the prediction of CI-AKI following percutaneous coronary interventions (PCIs). METHODS: This is a single-center, retrospective cohort study of adults undergoing PCI. Electronic medical records were reviewed to identify patients who underwent PCI between 2010 and 2019, derived from the National Cardiovascular Data Registry Cath-PCI registry for our hospital. Factor K (defined as contrast volume × serum creatinine/body weight) was calculated for every patient. A receiver operating characteristic (ROC) curve was constructed, and the Youden index was used to identify the optimal cut-off value for factor K in predicting severe (stages 2-3) CI-AKI. RESULTS: Of the 3,506 patients undergoing PCI, 255 (7.2%) developed CI-AKI, and 68 (26.7%) of the 255 experienced severe AKI. Factor K predicted all-stage CI-AKI (area under the ROC curve 0.649; 95% CI 0.611, 0.686) but had better performance for predicting severe (stages 2-3) AKI (0.736; 95% CI 0.674, 0.800). The optimal cut-off value for factor K in predicting severe CI-AKI was 2.5, with a corresponding sensitivity of 68.7% and specificity of 70.5%. On subgroup analyses, optimal cut-off values for factor K for high-risk groups were not significantly different from those of low-risk groups. CONCLUSION: Our study indicates that factor K in the MACD equation is an independent risk factor for the development of severe CI-AKI, with an optimal cut-off value of 2.5. If our findings are validated, the MACD equation should be revised to incorporate the coefficient of 2.5 instead of 5.

Malignancy-induced lactic acidosis in adult lymphoma.

Malignancy-induced lactic acidosis (MILA), a rare paraneoplastic phenomenon, is mostly described with hematologic malignancies (lymphomas and leukemias) but has also been reported with solid tumors. It is a subset of type B lactic acidosis being mediated without evidence of tissue hypoperfusion. Lymphoma-induced lactic acidosis is often considered an oncologic emergency and is associated with an increased risk of mortality and poor prognosis. It has a complex pathophysiology centered in the "Warburg effect," i.e., the programming of cancer cells to depend on aerobic glycolysis for promotion of their proliferation and anabolic growth. The treatment of lymphoma-induced lactic acidosis is focused on prompt administration of chemotherapy. The role of alkali therapy in this setting is controversial and has limited proven benefit with a potential for worsening the lactic acidosis. If alkali therapy is used in the presence of severe acidemia to optimize cardiovascular status, it should be administered judiciously.

Cost analysis of two modalities of continuous renal replacement therapy.

BACKGROUND: Continuous veno-venous hemofiltration (CVVH) and continuous veno-venous hemodialysis (CVVHD) are costly therapies reserved for use in critically ill patients with kidney failure. DESIGN: Quality improvement study at St. Elizabeth's Medical Center, Boston, MA, USA. SETTING AND PARTICIPANTS: Members of nephrology and pharmacy department, working alongside intensive care unit nursing staff and hospital administration, undertook an initiative to transition from CVVH to CVVHD, to simplify therapy administration, lessen need for electrolyte repletion, and reduce total treatment-related costs. QUALITY IMPROVEMENT PLAN: We postulated that conversion from CVVH to CVVHD would result in fewer filter clotting events, longer filter use (up to 72 hours), lower resource utilization, and confer overall cost benefit. Over 12 months, patients initiated on CVVH were identified. Following conversion to CVVHD, patients initiated on CVVHD over 9 months were identified. Patient characteristics, comorbidities, and hospital-related outcomes, as well as CRRT-related information including treatment modality, treatment duration, and treatment-related costs were obtained. MEASURES: Daily treatment-related costs, intensive care unit and hospital length of stay (LOS), and in-hospital mortality. RESULTS: During the baseline period, 77 patients were initiated on CVVH, and during the intervention period, 60 patients were initiated on CVVHD. Following conversion from CVVH to CVVHD, mean (±SD) daily total treatment cost decreased from $1813 ± $2143 to $775 ± $766 (P < 0.001). Conversion from CVVH to CVVHD had no impact on intensive care unit LOS (11.8 ± 9.7 vs. 12.4 ± 9.5 days; P = 0.53), hospital LOS (15.0 ± 11.1 vs. 16.4 ± 14.0 days; P = 0.89), or in-hospital mortality (58% vs. 60%; P = 0.85). LIMITATIONS: Nursing costs, costs of dialysis machine utilization, phosphate repletion, and systemic anti-coagulation were not studied. CONCLUSION: Transition from CVVH to CVVHD resulted in a significant cost benefit and reduced resource utilization. There was no difference in LOS and in-hospital mortality between the two treatment modalities.

Hepatitis B virus vaccine immune response and mortality in dialysis patients: a meta-analysis.

BACKGROUND: We performed a systematic review and meta-analysis to examine factors associated with HBV immune response in dialysis patients, and the association between the immune response to the HBV vaccine and mortality. METHODS: Electronic databases were searched for studies of dialysis patients that compared the characteristics of HBV vaccine responders and non-responders. Mortality was also analyzed according to the vaccine immune response (defined by hepatitis B surface antibody titer > 10 mIU/mL). Random-effects model meta-analyses were performed to compute a weighted mean difference (WMD), a pooled odds ratio (OR), and a pooled risk ratio (RR) between groups. RESULTS: We identified 61 studies with a total of 6628 dialysis patients who completed the course of HBV vaccination, 4582 responders (69%) and 2046 non-responders (31%). By meta-analysis, relative to non-responders, HBV vaccine responders had a higher dialysis adequacy as measured by Kt/V (WMD 0.08, P < 0.001), a higher serum albumin (WMD 0.12 gm/dL, P < 0.001), a higher normalized protein catabolic rate (WMD 0.12 gm/kg/day, P = 0.001), a higher hemoglobin (WMD 0.15 gm/L, P = 0.03), and a higher parathyroid hormone level (WMD 44 pg/mL, P = 0.004). HBV vaccine responders were younger (WMD - 4.68 years, P < 0.001), had been on dialysis for longer (WMD 2.60 months, P < 0.001), were less likely to have diabetes mellitus (pooled OR 0.65, P < 0.001), and were less likely to carry the human leukocyte antigen (HLA) DR3 (pooled OR 0.38, P = 0.01). Compared to non-responders, HBV vaccine responders had lower risk for all-cause mortality (pooled RR 0.64, P < 0.001), and lower risk for cardiovascular-related mortality (pooled RR 0.74, P = 0.02). CONCLUSION: In dialysis patients, the lack of immune response to the HBV vaccine is associated with older age, diabetes mellitus, HLA-DR3 status, shorter time on dialysis, lower nutritional status, lower hemoglobin, lower PTH level, and lower dialysis adequacy. Tackling some of these modifiable factors might improve the HBV vaccine immune response.

Design and implementation of an academic enrichment program to improve performance on the internal medicine in-training exam.

The internal medicine In-Training Exam (ITE) is administered at residency training programs to assess medical knowledge. Our internal medicine residency program witnessed a performance decline on the ITE between 2011 and 2014. The goal of this quality improvement project was to improve medical knowledge among residents as measured by an improvement in performance on the ITE, through the design and implementation of an Academic Enrichment Program (AEP). The AEP was designed in 2014-2015, and entailed a multipronged approach, including strengthening and tailoring of the didactic curriculum, establishment of a minimum conference attendance rate, and adoption of the New England Journal of Medicine Knowledge-Plus Internal Medicine Board Review platform. Residents performing below a pre-specified percentile rank cutoff on the previous year's ITE in any of the 12 content areas were required to complete a pre-specified percentage of the question bank in that specific topic. We examined a total of 164 residents enrolled in our program under the categorical training track. The mean (± SEM) ITE percentile for the 12 content areas increased significantly from calendar years 2011-2014 to 2015-2018, reflecting implementation of the AEP (p < 0.001). In brief, compared to the AEP-unexposed graduating classes of residents, the AEP-exposed graduating classes of residents displayed a significant improvement in the mean ITE percentile rank. This quality improvement project was carried out at a single institution. The implementation of a structured academic enrichment program significantly improves performance on the ITE.

Proton pump inhibitors and hypomagnesemia: A meta-analysis of observational studies.

BACKGROUND: Previous meta-analyses have suggested that there might be an association between the use of proton pump inhibitors (PPIs) and the development of hypomagnesemia, although the conclusions were no definitive. METHODS: To provide an update on this topic, we performed a meta-analysis of all observational studies that examined the association between the use of PPIs and the development of hypomagnesemia. A literature search was conducted in MEDLINE, Scopus and Cochrane Central Register of Controlled Trials (January 1970 to June 2018) to identify observational studies that examined the association between the use of PPIs and the incidence and prevalence of hypomagnesemia. STUDY ELIGIBILITY CRITERIA: In the absence of randomized controlled trials, we focused primarily on observational studies, including cross-sectional, case-control, retrospective, and prospective cohort studies. There was no limitation on sample size or study duration. Random-effect models meta-analyses were used to compute pooled unadjusted and adjusted odds ratios (ORs) for binary variables. RESULTS: Sixteen observational studies were identified, including 13 cross-sectional studies, 2 case-control studies, and 1 cohort study, with a total of 131,507 patients. The pooled percentage of PPI users was 43.6% (95% confidence interval [CI] 25.0%, 64.0%). Among PPI users, 19.4% (95% CI 13.8%, 26.5%) had hypomagnesemia compared to 13.5% (95% CI 7.9%, 22.2%) among nonusers. By meta-analysis, PPI use was significantly associated with hypomagnesemia, with a pooled unadjusted OR of 1.83 (95% CI 1.26, 2.67; P = .002) and a pooled adjusted OR of 1.71 (95% CI 1.33, 2.19; P < .001). In subgroup analyses, high-dose PPI use was associated with higher odds for hypomagnesemia relative to low-dose PPI use (pooled adjusted OR 2.13; 95% CI 1.26, 3.59; P = .005). CONCLUSION: Our findings are in support of the results of the previous meta-analyses. Furthermore, we found a dose-response between the PPI use and development of hypomagnesemia.

Effect of dialysate potassium and lactate on serum potassium and bicarbonate concentrations during daily hemodialysis at low dialysate flow rates.

BACKGROUND: Observational studies of hemodialysis patients treated thrice weekly have shown that serum and dialysate potassium and bicarbonate concentrations are associated with patient outcomes. The effect of more frequent hemodialysis on serum potassium and bicarbonate concentrations has rarely been studied, especially for treatments at low dialysate flow rate. METHODS: These post-hoc analyses evaluated data from patients who transferred from in-center hemodialysis (HD) to daily HD at low dialysate flow rates during the FREEDOM Study. The primary outcomes were the change in predialysis serum potassium and bicarbonate concentrations after transfer from in-center HD (mean during the last 3 months) to daily HD (mean during the first 3 months). RESULTS: After transfer from in-center HD to daily HD (data from 345 patients, 51 ± 15 years of age, mean ± standard deviation), predialysis serum potassium decreased (P < 0.001) by approximately 0.4 mEq/L when dialysate potassium concentration during daily HD was 1 mEq/L; no change occurred when dialysate potassium concentration during daily HD was 2 mEq/L. After transfer from in-center HD to daily HD (data from 284 patients, 51 ± 15 years of age), predialysis serum bicarbonate concentration decreased (P = 0.0022) by 1.0 ± 3.3 mEq/L when dialysate lactate concentration was 40 mEq/L but increased (P < 0.001) by 2.5 ± 3.5 mEq/L when dialysate lactate concentration was 45 mEq/L. These relationships were dependent on serum potassium and bicarbonate concentrations during in-center HD. CONCLUSIONS: Control of serum potassium and bicarbonate concentrations during daily HD at low dialysate flow rates is readily achievable; the choice of dialysate potassium and lactate concentration can be informed when transfer is from in-center HD to daily HD.

A quality improvement project to reduce overutilization of blood tests in a teaching hospital.

Objective: In hospitals, physicians-in-training are major contributors to the burden of tests ordered, increasing cost and resource utilization. We implemented an intervention to discourage overutilization of the complete blood count (CBC) and the basic metabolic panel (BMP). Methods: An intervention was designed, comprising education on high-value care and burden of over-testing, encouragement of competition, and use of positive reinforcement. The intervention was monitored by a test index determined by dividing the total number of a specific laboratory test ordered for a patient by the total number of hospital days. Results: Following a 6-month intervention, the mean CBC index decreased from 1.56 ± 0.02 to 1.45 ± 0.03 (p < 0.001), and the BMP index, from 1.35 ± 0.02 to 1.14 ± 0.03 (p < 0.001). There was significant interaction between the intervention and the slope of the BMP index trend (p = 0.03), but not the CBC index trend. The intervention had no impact on hospital length of stay and mortality. Conclusion: This quality improvement intervention is an effective approach to reducing overutilization of laboratory tests.

Trends in Avoidable Hospitalizations for Diabetes: Experience of a Large Clinically Integrated Health Care System.

Prevention quality indicators (PQIs) are used in hospital discharge data sets to identify quality of care for ambulatory care-sensitive conditions, such as diabetes. We examined the impact of clinical integration efforts on diabetes-related PQIs in a large community-based health care organization. Inpatient and observation hospitalizations from nine acute care hospitals were trended over 5 years (2012-2016). Using established technical specifications, annual hospitalizations rates were calculated for four diabetes-related PQIs: uncontrolled diabetes, short-term complications, long-term complications, and lower extremity amputations. The mean (±standard error of the mean) annual hospitalization rate for uncontrolled diabetes and short-term complications gradually increased from 1.3 ± 1.1 and 3.2 ± 2.5 per 1,000 discharges to 2.4 ± 1.7 (p < .001) and 7.1 ± 3.2 (p < .001) per 1,000 discharges, respectively. Conversely, the annual hospitalization rate for long-term complications and lower extremity amputations gradually decreased from 12.6 ± 1.1 and 88.6 ± 1.0 per 1,000 discharges to 6.5 ± 1.0 (p = .004) and 82.2 ± 1.0 per 1,000 discharges (p < .001). Trends generally persisted across payers, age, sex, and race. There was an inverse correlation between county income-per-capita and hospitalization rate for short-term complications (p = .04), long-term complications (p = .03), and lower extremity amputations (p < .001). Study limitations included use of administrative data, evolving coding practices, and ecological fallacy. Ambulatory-based efforts to optimize diabetes care can prevent long-term complications and reduce avoidable hospitalizations.