Hypothermia in neonates born by caesarean section at a tertiary hospital in South Africa.

Introduction: neonatal hypothermia has previously been noted in a large proportion of neonates born through Caesarean section at Chris Hani Baragwanath Hospital (CHBAH), yet no study in South Africa specifically explores the extent and severity of the threat of hypothermia to this population of neonates. Objectives: to describe the proportion and severity of neonatal hypothermia in infants born via Caesarean section at CHBAH as well as to document and describe possible contributing factors to neonatal hypothermia in this population. Methods: A neonatal unit's database records were reviewed for demographic information of patients and their mothers, clinical characteristics, body temperature and outcomes. Comparisons between normothermic and hypothermic neonates were performed. Results: Forty-one percent of neonates born via Caesarean section had hypothermia at birth, of whom 71%, 27% and 2% had mild, moderate and severe hypothermia, respectively. Prevalence of admission hypothermia was 42%. On average, neonates were born at term and were of normal birth weight. No maternal factors were found to be statistically significant. Bag-mask ventilation (BMV) and cardiopulmonary resuscitation (CPR) [3.4% vs. 0.7%, p-0.033; OR 2.67 (95% CI: 1.06-6.77)] and an elevated lactate [13.25 vs. 3.2 mmol/l, p-0.032; OR 1.13 (95% CI: 1.01-1.26)] were associated with hypothermia. In the multivariable logistic regression analysis hypothermia in neonates was associated with an elevated lactate. Conclusions: Prevalence of hypothermia in neonates born by Caesarean section is high and further prospective studies are required to elucidate the factors contributing to this.

Hepatitis C care cascade among persons born 1945-1965: 3 medical centers.

OBJECTIVES: Effective screening, diagnosis, and treatment are needed to reduce chronic hepatitis C virus (HCV) infection-associated morbidity and mortality. In order to successfully increase HCV treatment, it is necessary to identify and understand gaps in linkage of antibody-positive patients with newly identified HCV to subsequent HCV RNA testing, clinical evaluation, and treatment. STUDY DESIGN: To estimate attainment of HCV care cascade steps among antibody-positive patients with newly identified HCV, we conducted chart reviews of patients with a new positive HCV antibody test at 3 academic medical centers participating in the Birth-Cohort Evaluation to Advance Screening and Testing of Hepatitis C (BEST-C) study. METHODS: We tracked receipt of RNA testing, clinical evaluation, treatment initiation, and treatment completion among individuals born between 1945 and 1965 who were newly diagnosed as HCV antibody-positive between December 2012 and October 2015 at 3 BEST-C centers, predominantly from the participating medical centers' primary care practices and emergency departments. RESULTS: Of the 130 HCV-seropositive individuals identified, 118 (91%) had an RNA or genotype test, 75 (58%) were RNA-positive, 73 (56%) were linked to care, 22 (17% overall; 29% among RNA-positive) started treatment, and 21 (16%; 28% among RNA-positive) completed treatment. CONCLUSIONS: This analysis showed that although linkage to care was largely successful in the target birth cohort, the largest gap in the HCV care cascade was seen in initiating treatment. Greater emphasis on linking patients to clinical evaluation and treatment is necessary in order to achieve the public health benefits promised by birth-cohort testing.

Hepatitis C virus testing for case identification in persons born during 1945-1965: Results from three randomized controlled trials.

The Centers for Disease Control and Prevention and US Preventive Services Task Force recommend one-time hepatitis C virus (HCV) testing for persons born during 1945-1965 (birth cohort). However, few studies estimate the effect of birth cohort (BC) testing implementation on HCV diagnoses in primary care settings. We aimed to determine the probability of identifying HCV infections in primary care using targeted BC testing compared with usual care at three academic medical centers. From December 2012 to March 2014, each center compared one of three distinct interventions with usual care using an independently designed randomized controlled trial. Across centers, BC patients with no clinical documentation of previous HCV testing or diagnosis were randomly assigned to receive a one-time offering of HCV antibody (anti-HCV) testing via one of three independent implementation strategies (repeated-mailing outreach, electronic medical record-integrated provider best practice alert [BPA], and direct patient solicitation) or assigned to receive usual care. We estimated model-adjusted risk ratios (aRR) of anti-HCV-positive (anti-HCV+) identification using BC testing versus usual care. In the repeated mailing trial, 8992 patients (intervention, n = 2993; control, n = 5999) were included in the analysis. The intervention was eight times as likely to identify anti-HCV+ patients compared with controls (aRR, 8.0; 95% confidence interval [CI], 2.8-23.0; adjusted probabilities: intervention, 0.27%; control, 0.03%). In the BPA trial, data from 14,475 patients (BC, n = 8928; control, n = 5,547) were analyzed. The intervention was 2.6 times as likely to identify anti-HCV+ patients versus controls (aRR, 2.6; 95% CI, 1.1-6.4; adjusted probabilities: intervention, 0.29%; control, 0.11%). In the patient-solicitation trial, 8873 patients (BC, n = 4307; control, n = 4566) were analyzed. The intervention was five times as likely to identify anti-HCV+ patients compared with controls (aRR, 5.3; 95% CI, 2.3-12.3; adjusted probabilities: intervention, 0.68%; control, 0.11%). Conclusion: BC testing was effective in identifying previously undiagnosed HCV infections in primary care settings. (Hepatology 2018;67:524-533).

Economic Evaluation of a Home-Based Age-Related Macular Degeneration Monitoring System.

Background: Medicare recently approved coverage of home telemonitoring for early detection of incident choroidal neovascularization (CNV) among patients with age-related macular degeneration (AMD), but no economic evaluation has yet assessed its cost-effectiveness and budgetary impact. Objectives: To evaluate a home-based daily visual-field monitoring system using simulation methods and to apply the findings of the Home Monitoring of the Eye study to the US population at high risk for wet-form AMD. Design, Setting, and Participants: In this economic analysis, an evaluation of the potential cost, cost-effectiveness, and government budgetary impact of adoption of a home-based daily visual-field monitoring system among eligible Medicare patients was performed. Effectiveness and visual outcomes data from the Age-Related Eye Disease Study 2 Home Monitoring of the Eye study, treatment data from the Wills Eye Hospital Treat & Extend study, and AMD progression data from the Age-Related Eye Disease Study 1 were used to simulate the long-term effects of telemonitoring patients with CNV in one eye or large drusen and/or pigment abnormalities in both eyes. Univariate and probabilistic sensitivity analysis and an alternative scenario using the Treat & Extend study control group outcomes were used to examine uncertainty in these data and assumptions. Interventions: Home telemonitoring of patients with AMD for early detection of CNV vs usual care. Main Outcomes and Measures: Incremental cost-effectiveness ratio, net present value of lifetime societal costs, and 10-year nominal government expenditures. Result: Telemonitoring of patients with existing unilateral CNV or multiple bilateral risk factors for CNV (large drusen and retinal pigment abnormalities) incurs $907 (95% CI, -$6302 to $2809) in net lifetime societal costs, costs $1312 (95% CI, $222-$2848) per patient during 10 years from the federal government's perspective, and results in an incremental cost-effectiveness ratio of $35 663 (95% CI, cost savings to $235 613) per quality-adjusted life-year gained. Conclusions and Relevance: Home telemonitoring of patients with AMD who are at risk for CNV was cost-effective compared with scheduled examinations alone. Monitoring patients with existing CNV in one eye is cost saving, but monitoring is generally not cost-effective among patients with low risk of CNV, including those with no or few risk factors. With Medicare coverage, monitoring incurs budgetary expenditures for the government but is cost-saving for patients at high risk of AMD. Monitoring could be cost saving to society if monitoring reduced the frequency of scheduled examinations or led to a reduction of one or more injections of ranibizumab.

Assessing acquired rhabdomyolysis in adults.

The presentation of patients with rhabdomyolysis is variable and can range in severity from asymptomatic serum elevations of creatine kinase to life-threatening electrolyte disturbances and acute kidney injury. Clinicians must have a high suspicion for rhabdomyolysis and be familiar with the risk factors for developing this condition. This article focuses on prompt recognition and evidence-based approaches to diagnose and treat rhabdomyolysis.

Implementation of Birth-Cohort Testing for Hepatitis C Virus.

Hepatitis C virus infection affects approximately 2.2 to 3.2 million Americans. In 2012, the Centers for Disease Control and Prevention recommended a one-time antibody test of all persons belonging to the 1945-1965 birth cohort. Efforts to implement this recommendation in clinical settings are in their infancy; this case study report therefore seeks to share the experiences of three sites that implemented interventions to increase birth-cohort testing through participation in the Birth-cohort Evaluation to Advance Screening and Testing for Hepatitis C. At each site, project managers completed standardized questionnaires about their implementation experiences, and a qualitative analysis was conducted of the responses. The testing interventions used in-person recruitment, mail recruitment, and an electronic health record prompt. Sites reported that early efforts to obtain stakeholder buy-in were critical to effectively implement and sustain interventions and that the intervention required additional staffing resources beyond those being used for risk-based testing. In each case, administrative barriers were more extensive than anticipated. For the electronic health record-based intervention, technological support was critical in achieving study goals. Despite these barriers, interventions in all sites were successful in increasing rates of testing and case identification, although future studies will need to evaluate the relative costs and benefits of each intervention.

Assessing upper gastrointestinal bleeding in adults.

Acute upper gastrointestinal (GI) bleeding is a potentially life-threatening condition requiring accurate, prompt, and appropriate patient evaluation and management. Clinicians of all specialties must know the best practices for preventing and managing upper GI bleeding. This article focuses on assessing and managing adults with acute nonvariceal upper GI bleeding.

Assessing esophageal dysphagia.

Dysphagia, or difficulty swallowing, is a common problem. Although most cases are attributable to benign disease processes, dysphagia is also a key symptom in several malignancies, making it an important symptom to evaluate. The differential diagnosis of dysphagia requires an understanding of deglutition, in particular the oropharyngeal versus esophageal stages. Stroke is the leading cause of oropharyngeal dysphagia, which is common in older adults and frequently presents as part of a broader complex of clinical manifestations. In esophageal dysphagia, difficulty swallowing is often the main complaint and is caused by localized neuromuscular disorders or obstructive lesions.

Evaluating the adult with new-onset pleural effusion.

PAs play an essential role in recognizing new-onset pleural effusion in adults. This article reviews risk factors, patient assessment, diagnostic testing, initial management, and treatment.