The incidence of refeeding syndrome and the nutrition management of severely malnourished inpatients with eating disorders: An observational study.

OBJECTIVE: Nutritional rehabilitation and weight restoration are often critical for the treatment of eating disorders (ED), yet are restricted by the potential risk of refeeding syndrome (RFS). The primary objective was to determine the incidence of RFS. Secondary objectives were to explore predictive factors of RFS and describe its impact on treatment goals for patients with ED. METHOD: This retrospective observational study reviewed the nutrition management for patients admitted to a quaternary hospital for ED treatment from 2018 to 2020. Data were collected during the first 4 weeks of admission and included anthropometry, energy prescription, incidence and severity of RFS, and electrolyte and micronutrient prescription. Outcomes included incidence of RFS, energy prescription and advancement, and weight change. RESULTS: Of 423 ED admissions, 217 patients (median [interquartile range, IQR] age 25 [21-30.5] years; 210 [97%] female) met inclusion criteria. Median (IQR) body mass index (BMI) on admission was 15.5 (14.1-17.3) kg/m2 . The mean (standard deviation) length of admission was 35 (7.3) days. Median (IQR) initial energy prescription was 1500 (930-1500) kcal/day. Seventy-three (33%) patients developed RFS; 34 (16%) mild, 27 (12%) moderate, and 12 (5%) severe. There was no association between RFS severity and admission BMI, energy prescription, or prescription of prophylactic electrolytes or micronutrients. Lower admission weight was associated with RFS (odds ratio 0.96, 95% confidence interval [0.93-1.00], p = .035). Less than half of the participants met the weight gain target (>1 kg per week) in the first 3 weeks of admission. DISCUSSION: The incidence of severe RFS was low in this cohort and was associated with lower admission weight. PUBLIC SIGNIFICANCE: This study is one of the largest studies to utilize consensus-defined criteria to diagnose RFS among adult patients admitted for treatment of an ED. This population is still considered to be at risk of RFS and will require close monitoring. The results add to the growing body of research that restriction of energy prescription to prevent RFS may not require the level of conservatism traditionally practiced.

Effect of a Multiorgan Focused Clinical Ultrasonography on Length of Stay in Patients Admitted With a Cardiopulmonary Diagnosis: A Randomized Clinical Trial.

Importance: There are accumulating data about the utility of diagnostic multiorgan focused clinical ultrasonography (FCU) in the assessment of patients admitted with cardiopulmonary symptoms. Objective: To determine whether adding multiorgan FCU to the initial clinical evaluation of patients admitted with cardiopulmonary symptoms reduces hospital length of stay, hospital readmissions, and in-hospital costs. Design, Setting, and Participants: This is a prospective, parallel-group, superiority, randomized clinical trial with a 1:1 allocation ratio. The study was conducted at The Royal Melbourne Hospital, a tertiary public hospital located in Melbourne, Victoria, Australia. Adults aged 18 years or older admitted to the internal medicine ward with a cardiopulmonary diagnosis were enrolled between September 2018 and December 2019 and were followed up until hospital discharge. Data analysis was performed from August 2020 to January 2021. Interventions: The intervention involved an internal medicine physician-performed heart, lung, and 2-point vein compression FCU in addition to standard clinical evaluation. Main Outcomes and Measures: The primary outcome was the difference in the mean length of hospital stay, defined as the number of hours from admission to the internal medicine ward to hospital discharge. A difference of 24 hours was defined as clinically important. Secondary outcomes included hospital readmissions at 30 days and hospital care costs. Results: A total of 250 participants were enrolled and 2 were excluded, leaving 248 participants (mean [SD] age, 80.1 [11.0] years; 121 women [48.7%]) in the final analysis. There were 124 patients in the intervention group and 124 patients in the control group. The most common initial diagnoses were acute decompensated heart failure (113 patients [45.5%]), pneumonia (45 patients [18.1%]), and exacerbated chronic pulmonary disease (32 patients [12.9%]). The length of hospital stay was 113.4 hours (95% CI, 91.7-135.1 hours) in the FCU group and 125.3 hours (95% CI, 101.7-148.8 hours) in the control group (P = .53). The 30-day readmission rate was not different between groups (FCU vs control, 20 of 124 patients [16.1%] vs 15 of 124 patients [12.0%]), nor were total in-hospital costs (FCU vs control, A$7831.1 [95% CI, A$5586.1-A$10 076.1] vs A$7895.7 [95% CI, A$6385.9-A$9.405.5]). Conclusions and Relevance: In this randomized clinical trial, adult patients admitted to an internal medicine ward with a cardiopulmonary diagnosis, who underwent multiorgan FCU of the heart, lungs, and lower extremities veins during their initial clinical assessment, did not have a shorter hospital length of stay by more than 24 hours, compared with patients who received standard care. Trial Registration: Australian New Zealand Clinical Trials Registry Identifier: ACTRN12618001442291.

A Survey on Knowledge Gaps in Assessment and Management of Severe Drug Hypersensitivity Reactions: Multicenter Cross-Sectional Study of Australian Health Care Providers.

Severe drug hypersensitivity reactions (DHRs) are often encountered by health care professionals (HCPs). We evaluated knowledge of doctors and pharmacists in the assessment and management of severe DHRs using a structured questionnaire. A cross-sectional study was conducted in 4 metropolitan hospital networks in Melbourne, Australia. A 13-question, scenario-based multiple-choice questionnaire to assess specific knowledge domains in drug hypersensitivity syndrome recognition, causality attribution, cross-reactivity patterns, appropriate diagnostic tests, and therapy was administered to HCPs of various vocation and specialty groups. Data were analyzed according to profession, self-reported experience, and preparedness in managing severe DHRs. Two hundred thirty-eight participants (45.0% senior doctors, 24.4% junior doctors, and 30.7% pharmacists) across a range of subspecialties achieved an overall median score of 7 (IQR, 5-8)-overall 55.6% correct responses to all questions-with senior doctors outperforming junior doctors and pharmacists (P < .001). The best performance by all participants was in DHR syndrome recognition (60.9%), and the poorest was in diagnostics/therapy (52.0%). HCP group and experience level were significantly associated with better performance in the knowledge domains of cross-reactivity and diagnostics/therapy (P = .003 and < .001, respectively), but not in the domains of syndrome recognition and causality attribution (P > .05). Levels of self-reported preparedness in DHR management were not associated with performance rates in any of the knowledge domains. This study demonstrated significant knowledge gaps in the recognition and management of severe drug hypersensitivity reactions. Targeted multidisciplinary education of staff caring for these patients is needed to improve knowledge gaps.

Advocacy, Strategy and Tactics Used to Confront Corporate Power: The Nestlé Boycott and International Code of Marketing of Breast-milk Substitutes.

Douglas A. Johnson began his career as a human rights activist while earning his undergraduate degree in philosophy (1975) at Macalester College in the United States. He lived at Gandhi's ashram in India to study nonviolent organizing (1969 to 1970). He served as the director of the Third World Institute in Minneapolis, MN, USA (1973-1979), which functioned as the international social justice program of the Archdiocese of Minneapolis and St. Paul. Johnson's work included creating and running a political collective; leading development study tours into villages in Guatemala and Honduras; and investigating how transnational companies (e.g., Nestlé) were penetrating the developing world. He was the co-founder of the Infant Formula Action Coalition (INFACT), elected national chairperson (1977-1985), and appointed as Executive Director (1978-1984). His role included representing INFACT before national and international organizations, the human milk substitute industry, the US Congress and Executive Branch, and the press. He initiated and coordinated the first international grass-roots consumer boycott (against Nestlé) in ten nations. He was also a co-founder of the International Nestlé Boycott Committee and the International Baby Food Action Network (IBFAN). He earned a Master's in Public and Private Management at Yale University (1988). Then he became the first Executive Director of the Center for Victims of Torture, in Minneapolis (1988-2012), the first treatment center for torture victims in the US. Since 2013, he has been teaching human rights theory and practice, and sharing lessons he has learned, as a Lecturer in Public Policy at the Harvard Kennedy School, Harvard University (US). (This interview was conducted via Zoom and transcribed verbatim. It has been edited for ease of readability. DJ refers to Doug Johnson and LD refers to Laura Duckett.).

Incidence, features and management of radionecrosis in melanoma patients treated with cerebral radiotherapy and anti-PD-1 antibodies.

BACKGROUND: Brain radiotherapy is used in the management of melanoma brain metastases (MBM) and can result in radionecrosis. Anti-PD-1 is active in the brain and may increase the risk of radionecrosis when combined with radiotherapy. We studied the incidence, associated factors and management of radionecrosis in longer-term survivors with MBM treated with this combination. METHODS: Patients with MBM treated with radiotherapy and anti-PD-1 who survived >1 year were identified to determine radionecrosis incidence (Cohort A, n = 135). Cohort A plus additional radionecrosis cases were examined for factors associated with radionecrosis and management (Cohort B, n = 148). RESULTS: From Cohort A, 17% developed radionecrosis, with a cumulative incidence at 2 years of 18%. Using Cohort B, multivariable analysis confirmed an association between radionecrosis and elevated lactate dehydrogenase (p = 0.0496) and prior treatment with ipilimumab (p = 0.0319). Radionecrosis was diagnosed based on MRI (100%), symptoms (69%) and pathology (56%). Treatment included corticosteroids, bevacizumab and neurosurgery. CONCLUSIONS: Radionecrosis is a significant toxicity in longer-term melanoma survivors with MBM treated with anti-PD-1 and radiotherapy. Identification of those at risk of radionecrosis who may avoid radiotherapy is required.

Endoscopic investigation in non-iron deficiency anemia: a cost to the health system without patient benefit.

BACKGROUND AND AIMS: The indication for endoscopy to investigate anemia of causes other than iron deficiency is not clear. Increasing numbers of endoscopic procedures for anemia raises concerns about costs to the health system, waiting times, and patient safety. The primary aim of this study was to determine the diagnostic yield of endoscopy in patients referred to undergo investigation for anemia. Secondary aims were to identify additional factors enabling the risk stratification of those likely to benefit from endoscopic investigation, and to undertake a cost analysis of performing endoscopy in this group of patients. METHODS: We performed a retrospective review of endoscopy referrals for the investigation of anemia over a 12-month period at a single center. The patients were divided into three groups: those who had true iron deficiency anemia (IDA), tissue iron deficiency without anemia (TIDWA), or anemia of other cause (AOC). Outcome measures included finding a lesion responsible for the anemia and a significant change of management as a result of endoscopy. A costing analysis was performed with an activity-based costing method. RESULTS: We identified 283 patients who underwent endoscopy to investigate anemia. A likely cause of anemia was found in 31 of 150 patients with IDA (21 %) and 0 patients in the other categories (P < 0.001). A change of management was observed in 35 patients with IDA (23 %), 1 of 14 patients with TIDWA (7.14 %), and 8 of 119 patients with AOC (6.7 %) (P < 0.001). The cost of a single colonoscopy or gastroscopy was approximated to be $ 2209. CONCLUSIONS: Endoscopic investigation for non-IDA comes at a significant cost to our institution, equating to a minimum of $ 293 797 per annum in extra costs, and does not result in a change of management in the majority of patients. No additional factors could be established to identify patients who might be more likely to benefit from endoscopic investigation. The endoscopic investigation of non-IDA should be minimized.

Going Upstream: Coordination to Improve CKD Care.

Care coordination for patients with chronic kidney disease has been shown to be effective in improving outcomes and reducing costs. However, few patients with CKD benefit from this systematic management of their kidney disease and other medical conditions. As a result, outcomes for patients with kidney disease are not optimal, and their cost of care is increased. For those patients who transition to kidney failure treatment in the United States, the transition does not go as well as it could. The effectiveness of treatments to delay progression of kidney disease in contemporary clinical practice does not match the efficacy of these treatments in clinical trials. Conservative care for kidney disease, which should be an option for patients who are very old and very sick, is not considered often enough or seriously enough. Opportunities for early and even pre-emptive transplantation are missed, as are opportunities for home dialysis. The process of dialysis access creation is rarely optimal. The consequence is care which is not as good as it could be, and much more expensive than it should be. We describe our initial efforts to implement care coordination for chronic kidney disease in routine clinical care and attempt to project some of the benefits to patients and the cost savings.

Cherry Picking in the 'Aina: Inequalities of Access to Dermatologic Care in Hawai'i.

There is evidence that people who are insured by Medicaid have difficulty accessing health care from private providers. This study documents access to dermatology care for a hypothetical patient insured by Medicaid in the State of Hawai'i. Posing as young Medicaid patient with a changing mole, we called all dermatologists listed on the American Academy of Dermatology website and requested an appointment to be seen. Only 23% of dermatologists contacted accept all Medicaid plans and an additional 12% accept some. Thus 65% of dermatologists called do not provide specialist care to Hawai'i's Medicaid population.

Guiding principles and checklist for population-based quality metrics.

The Centers for Medicare and Medicaid Services oversees the ESRD Quality Incentive Program to ensure that the highest quality of health care is provided by outpatient dialysis facilities that treat patients with ESRD. To that end, Centers for Medicare and Medicaid Services uses clinical performance measures to evaluate quality of care under a pay-for-performance or value-based purchasing model. Now more than ever, the ESRD therapeutic area serves as the vanguard of health care delivery. By translating medical evidence into clinical performance measures, the ESRD Prospective Payment System became the first disease-specific sector using the pay-for-performance model. A major challenge for the creation and implementation of clinical performance measures is the adjustments that are necessary to transition from taking care of individual patients to managing the care of patient populations. The National Quality Forum and others have developed effective and appropriate population-based clinical performance measures quality metrics that can be aggregated at the physician, hospital, dialysis facility, nursing home, or surgery center level. Clinical performance measures considered for endorsement by the National Quality Forum are evaluated using five key criteria: evidence, performance gap, and priority (impact); reliability; validity; feasibility; and usability and use. We have developed a checklist of special considerations for clinical performance measure development according to these National Quality Forum criteria. Although the checklist is focused on ESRD, it could also have broad application to chronic disease states, where health care delivery organizations seek to enhance quality, safety, and efficiency of their services. Clinical performance measures are likely to become the norm for tracking performance for health care insurers. Thus, it is critical that the methodologies used to develop such metrics serve the payer and the provider and most importantly, reflect what represents the best care to improve patient outcomes.

Ask the experts: future of the pharmaceutical industry. Interview by Future Medicinal Chemistry.

The pharmaceutical industry is facing numerous, well-documented challenges - from the effects of patent expirations to high attrition rates in the drug-development pipeline. Future Medicinal Chemistry has invited a group of leaders from academia and industry to express their views on where the industry is heading and speculate as to what role medicinal chemists will play in the future.

Posttraumatic stress disorder mediates the relationship between mild traumatic brain injury and health and psychosocial functioning in veterans of Operations Enduring Freedom and Iraqi Freedom.

This study evaluated whether posttraumatic stress disorder (PTSD) mediated the relationship between mild traumatic brain injury (MTBI) and general health ratings, psychosocial functioning, and perceived barriers to receiving mental healthcare 2 years following return from deployment in veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). A total of 277 OEF/OIF veterans completed the Connecticut OEF/OIF Veterans Needs Assessment Survey; 18.8% of the sample screened positive for MTBI. Compared with respondents who screened negative for MTBI, respondents who screened positive for MTBI were younger, more likely to have PTSD, more likely to report fair/poor overall health and unmet medical and psychological needs, and scored higher on measures of psychosocial difficulties and perceived barriers to mental healthcare. Injuries involving loss of consciousness were associated with greater work-related difficulties and unmet psychological needs. PTSD mediated the relationship between MTBI and all of these outcomes. These results underscore the importance of assessing PTSD in OEF/OIF veterans who screen positive for MTBI.

The incidence of duplicate genetic testing.

PURPOSE: Duplicate genetic testing (DGT) should give the same results as the initial genetic test. Therefore, DGT is indicated only in the rare instances where the initial results require confirmation. The objective of this study was to determine the incidence of DGT by reviewing TPMT, HFE, and CYP450 2D6 polymorphism testing performed in our institution's laboratories in 2006. A secondary objective was to determine the savings in charges that resulted from a system in place to limit HFE DGT. METHODS: A retrospective records review at an academic medical center. RESULTS: The percentage of patients having the same genetic test more than once in 2006 was 3.3% (253/7710) for TPMT, 0.3% for HFE (24/7851), and 0.9% (4/433) for CYP450 2D6 testing. Retail laboratory charges for the DGT identified in 2006 were $76,728. To estimate the incidence of DGT over a longer period of time than 2006, an all-time records review was performed on a subset of internal patients and found the all-time incidence of DGT for TPMT, HFE, and CYP450 2D6 testing to be 6.9%, 1.9%, and 0.9%, respectively. No case of DGT with an appropriate indication for duplicate testing was found. A system in place to decrease HFE DGT is estimated to have saved $77,479 in charges for 2006 (95% CI, $35,512-184,015). CONCLUSIONS: Indicated DGT is rare and decreasing DGT could result in significant savings. Institutions should consider implementing a systems-based process to limit DGT.

Sequence assessment of comigrating AFLPTM bands in Echinacea -- implications for comparative biological studies.

The extent of sequence identity among clones derived from monomorphic and polymorphic AFLPTM polymorphism bands was quantified. A total of 79 fragments from a monomorphic band of 273 bp and 48 fragments from a polymorphic band of 159 bp, isolated from individuals belonging to different populations, varieties, and species of Echinacea, were cloned and sequenced. The monomorphic fragments exhibited above 90% sequence identity among clones within samples. Sequence identity within variety ranged from 82.78% to 94.87% and within species from 75.82% to 98.9% and was 57.97% in the genus. The polymorphic fragments exhibited much less sequence identity. In some instances, even two clones from the same fragment were different in their size and sequence. Within sample, clone sequence identity ranged from 100% to 51.57%, within variety from 33.33% to 100% in one variety, and from 23.66% to 45% within species and was as low as 1.25% within the genus. In addition, sequences of the same size were aligned to verify the nature of their sequence dissimilarity/similarity. Within each size group, identical sequences were found across species and varieties. In general, comigrating bands cannot be considered homologous. Thus, the use of AFLPTM band data for comparative studies is appropriate only if the results emanating from such analyses are considered as approximations and are interpreted as phenotypic but not genotypic.