Survival benefit associated with early detection of spontaneous bacterial peritonitis in veteran inpatients with cirrhotic ascites.

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is common in hospitalized cirrhotic patients with ascites and carries high mortality. This study aimed to determine whether early diagnostic paracentesis (EDP) <12 h of hospitalization conveys an intermediate-term (6-month) survival benefit in cirrhotic patients diagnosed with SBP. METHODS: Consecutive US veterans with cirrhosis diagnosed with SBP over 13 years at a single VA medical center were reviewed retrospectively. Kaplan-Meyer analyses assessed the effects of EDP on survival. RESULTS: A total of 79 cirrhotic patients were diagnosed with SBP (61.8 ± 8.8 years, n = 77 male, n = 52 [66.8%] Caucasian, n = 23 [29.1%] African-American). Underlying liver diseases included hepatitis c viral infection (HCV) (17.5%), alcohol (28.6%), alcohol and HCV (30.1%), and cryptogenic/metabolic (15.9%). Median baseline model for end-stage liver disease (MELD) was 12 (range 6-34), and median MELD at presentation was 18. Seven subjects had a history of hepatocellular carcinoma (11.1%), and 26 (41.3%) presented with sepsis. Thirty-three (52.4%) subjects died within 6 months after the SBP admission. Of the subjects, 41 (65.1%) underwent EDP, of which 23 (56.0%) survived at least 6 months, compared to only 7 of the 22 patients (31.8%) undergoing paracentesis >12 h from presentation (P = 0.057). The maximal benefit of EDP on survival was observed beyond days 14 and 30; at these time points, no statistical difference in mortality was discernable (P = 0.55 and 0.71). In a multivariate model including age, MELD at admission, hepatocellular cancer, and sepsis criteria, EDP (p 0.034) positively impacted patient survival at 6 months. CONCLUSIONS: EDP is associated with improved 6-month mortality in cirrhotic patients with ascites. In this veteran cohort, EDP was as important as MELD as a predictor of intermediate-term survival.

Upper esophageal sphincter metrics on high-resolution manometry differentiate etiologies of esophagogastric junction outflow obstruction.

BACKGROUND: Upper esophageal sphincter (UES) metrics on high-resolution manometry (HRM), particularly nadir UES residual pressure (UES-RP), are abnormal in achalasia and may help characterize the underlying mechanism or predict management outcome in esophagogastric junction outflow obstruction (EGJOO). METHODS: A database of consecutive patients undergoing esophageal HRM from 2008 to 2013 yielded 134 patients (59.8 ± 1.4 years, 68% F) with EGJOO. Final clinical diagnoses and treatment response were extracted from chart review. Esophageal body, UES, and lower esophageal sphincter (LES) metrics were compared between EGJOO and asymptomatic healthy controls (n = 16, 27.7 ± 0.7 years, 56% F). Logistic regression evaluated differences between HRM metrics amongst etiologies of EGJOO grouped into motor versus mechanical disorders. KEY RESULTS: Distal contractile integral, distal latency, and nadir UES-RP were significantly different between EGJOO subgroups (P ≤ 0.01 for each comparison), but only nadir UES-RP remained independently predictive of subgroups (adjusted odds ratio 1.15, 95% confidence intervals 1.05-1.27, P < 0.01). Nadir UES-RP was highest in achalasia variants, and lowest in mechanical EGJOO and controls (P < 0.001). Of 19 patients who underwent LES myotomy, durable benefit was reported by 68.4% over mean 3.6 years of follow-up. Significantly higher nadir UES-RP was noted with symptom relief (3.4 vs -0.7 mm Hg with symptom recurrence, 95% confidence intervals of difference = 1.35-6.83). A threshold UES-RP of ≥2.0 mm Hg yielded a sensitivity of 84.6% and specificity of 83.3% in predicting symptom resolution following myotomy. CONCLUSIONS AND INFERENCES: Nadir UES-RP offers clues to differentiation of subtypes within EGJOO and may predict symptom outcome from myotomy.

Supporting Implementation Research to Improve Coverage and Uptake of HIV Related Interventions.

In 2015, Global Affairs Canada joined other members of the United Nations to establish the Sustainable Development Goals, which include the elimination of AIDS by 2030. Innovation is an important part of accelerating the response against HIV and ensuring success in eliminating AIDS by 2030. This is the reason Global Affairs Canada decided to partner with the World Health Organization, to support the INtegration and Scaling Up PMTCT through Implementation REsearch (INSPIRE) initiative, to learn how HIV interventions can be successfully integrated with other essential health services for mothers and children, especially among the most vulnerable populations. Canada also believes that the empowerment of women and girls will be critical to eliminating AIDS. INSPIRE is the evidence that providing women with the knowledge and skills necessary to prevent, treat, and manage HIV enables them to become experts and agents of change in their families and communities. We know that when women are empowered with critical information regarding their health, there is greater retention in care which leads to improved treatment adherence and ultimately helps to reduce the rate of new infections. Global Affairs Canada is proud to have supported the World Health Organization in this effort.

Do Consultants Follow Up on Tests They Recommend? Insights from an Academic Inpatient Gastrointestinal Consult Service.

BACKGROUND: Inpatient care is a fundamental part of gastroenterology training and involves the recommendation, performance, and interpretation of diagnostic tests. However, test results are not always communicated to patients or treating providers. We determined the process of communication of test results and recommendations in our inpatient gastroenterology (GI) consult service. METHODS: Test recommendations on 304 consecutive new GI consults (age 60.2 ± 1.0 year) over a 2-month period were recorded. Demographic factors (age, race, gender, zip code, insurance status) were extracted from the electronic medical record (EMR). Charts were independently reviewed 6 months later to determine results of recommended tests, follow-up of actionable test results, 30-day readmission rates, and predictors of suboptimal communication. RESULTS: Of 490 recommended tests, 437 (89.2%) were performed, and 199 (45.5%) had actionable findings. Of these, 48 (24.1%) did not have documented follow-up. Failure of follow-up was higher for upper endoscopy (31.9%) compared to colonoscopy (18.0%, p = 0.07). Women (p = 0.07), patients on Medicare (p = 0.05), and procedures supervised by advanced GI fellows (p = 0.06) were less likely to receive follow-up. Median income and identification of a primary provider did not influence follow-up rates; 30-day readmission rates were not impacted. Female gender, insurance (Medicare) status, and attending type remained independent predictors of failure of follow-up on multivariate regression (p ≤ 0.03). CONCLUSIONS: Failure to follow up test results on inpatient services at a large academic center was unacceptably high. Maximizing personnel participation together with diligence and technology (EMR) will be required to improve communication.

Statins Are Underutilized in Patients with Nonalcoholic Fatty Liver Disease and Dyslipidemia.

BACKGROUND: Cardiovascular disease provides the greatest mortality risk in patients with nonalcoholic fatty liver disease (NAFLD). Clinical practice guidelines recommend statins to treat dyslipidemia in patients with NAFLD; however, the extent to which such patients receive statins has not been studied. METHODS: We conducted a structured medical record review to assess for appropriate statin use in patients in a Veterans Administration facility with dyslipidemia and NAFLD as well as a parallel cohort without NAFLD. Appropriate statin use was defined as receipt of statins without a clinically significant, unjustified dose change during the study period. RESULTS: Of 255 patients with NAFLD and dyslipidemia, 152 (59.6 %) patients received appropriate statin care. Primary care providers (PCPs) recognized the presence of NAFLD in 106 patients (41.6 %). Among the 63 of 106 (59.4 %) patients who were on a statin at the time of detection, 24 (38.1 %) received a clinically significant dose reduction or discontinuation. Patients whose PCPs recognized the presence of NAFLD (adjusted OR = 0.34, 95 % CI = 0.18-0.64) were less likely to receive appropriate statin care than patients with undetected NAFLD. Also, patients with detected NAFLD were less likely than dyslipidemic patients without NAFLD to receive appropriate statin care (OR = 0.45, 95 % CI = 0.25-0.79). CONCLUSION: Statins are underused in patients with NAFLD and dyslipidemia. The most important determinant for inappropriate statin use was PCP recognition of NAFLD. While these results need to be confirmed in non-VA healthcare systems, they highlight the need for efforts to enhance PCP knowledge of existing guidelines regarding statin use in NAFLD.

Nonalcoholic fatty liver disease is underrecognized in the primary care setting.

OBJECTIVES: The prevalence and disease burden of nonalcoholic fatty liver disease (NAFLD) are increasing. Nonetheless, little is known about the processes related to identification, diagnosis, and referral of patients with NAFLD in routine clinical care. METHODS: Using automated data, we isolated a random sample of patients in a Veterans Administration facility who had ≥2 alanine transaminase (ALT) values >40 IU/ml >6 months apart in the absence of any positive results for hepatitis C RNA, hepatitis B surface antigen, or screens for excess alcohol use. We conducted a structured medical record review to confirm NAFLD and abstracted data from the primary care providers' notes for (i) recognition of abnormal ALT levels, (ii) mention of NAFLD as a possible diagnosis, (iii) recommendations for diet or exercise, and (d) referral to a specialist for further NAFLD evaluation. Using a multilevel logistic regression model, we identified patient demographic, clinical, comorbidity, and health-care utilization factors associated with recognition and receipt of early NAFLD care. RESULTS: Of 251 patients identified with NAFLD by our methods, 99 (39.4%) had documentation in medical record notes of abnormal ALT, 54 (21.5%) had NAFLD mentioned as a possible diagnosis, 37 (14.7%) were counseled regarding diet and exercise, and 26 (10.4%) were referred to a specialist. Only the magnitude of ALT elevation (adjusted odds ratio (OR) for ALT >80 IU/ml vs. <80 IU/ml=4.4, 95% confidence interval (CI)=2.65-7.30) and proportion of elevation (adjusted OR for >50% vs. <50% of ALT values >40 IU/ml=1.8, 95% CI=1.03-3.14) were associated with receiving specified NAFLD care. Only 3% of patients at a high risk of fibrosis (NAFLD fibrosis score >0.675) were referred to specialists. CONCLUSIONS: Most patients in care who may have NAFLD are not being recognized and evaluated for this condition. Our data suggest that providers may be using an incorrect heuristic in delivering NAFLD care by concentrating on those with high ALT levels.

Introducing INSPIRE: an implementation research collaboration between the Department of Foreign Affairs, Trade and Development Canada and the World Health Organization.

The government of Canada, through the Department of Foreign Affairs, Trade and Development (DFATD) has supported global efforts to reduce the impact of the HIV pandemic. In 2012, WHO and DFATD launched an implementation research initiative to increase access to interventions that were known to be effective in the prevention of mother-to-child transmission of HIV and to learn how these could be successfully integrated with other essential services for mothers and children. In addition to facilitating the implementation research projects, DFATD and WHO promoted four approaches: (1) Country-specific implementation research prioritization exercises, (2) Ministry of Health involvement, (3) Country-led, innovative, high-quality research, and (4) Leveraging regional networks and learning opportunities. While no single aspect of INSPIRE is unique, the process endeavors to promote and support high-quality, rigorous, locally-led implementation research that will have a substantial impact on the health and survival of HIV-infected women and their children.