Urinary kidney injury molecule 1 (KIM-1) and interleukin 18 (IL-18) as risk markers for heart failure in older adults: the Health, Aging, and Body Composition (Health ABC) Study.

BACKGROUND: Kidney damage and reduced kidney function are potent risk factors for heart failure, but existing studies are limited to assessing albuminuria or estimated glomerular filtration rate (eGFR). We evaluated the associations of levels of urinary biomarkers of kidney tubular injury (interleukin 18 [IL-18] and kidney injury molecule 1 [KIM-1]) with future risk of heart failure. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 2,917 participants without heart failure in the Health, Aging, and Body Composition (Health ABC) cohort. PREDICTORS: Ratios of urine KIM-1, IL-18, and albumin to creatinine (KIM-1:Cr, IL-18:Cr, and ACR, respectively). OUTCOMES: Incident heart failure over a median follow-up of 12 years. RESULTS: Median values of each marker at baseline were 812 (IQR, 497-1,235)pg/mg for KIM-1:Cr, 31 (IQR, 19-56)pg/mg for IL-18:Cr, and 8 (IQR, 5-19) mg/g for ACR. 596 persons developed heart failure during follow-up. The top quartile of KIM-1:Cr was associated with risk of incident heart failure after adjustment for baseline eGFR, heart failure risk factors, and ACR (HR, 1.32; 95% CI, 1.02-1.70) in adjusted multivariate proportional hazards models. The top quartile of IL-18:Cr also was associated with heart failure in a model adjusted for risk factors and eGFR (HR, 1.35; 95% CI, 1.05-1.73), but was attenuated by adjustment for ACR (HR, 1.15; 95% CI, 0.89-1.48). The top quartile of ACR had a stronger adjusted association with heart failure (HR, 1.96; 95% CI, 1.53-2.51). LIMITATIONS: Generalizability to other populations is uncertain. CONCLUSIONS: Higher urine KIM-1 concentrations were associated independently with incident heart failure risk, although the associations of higher ACR were of stronger magnitude.

Serum bicarbonate concentrations and kidney disease progression in community-living elders: the Health, Aging, and Body Composition (Health ABC) Study.

BACKGROUND: In populations with prevalent chronic kidney disease (CKD), lower serum bicarbonate levels are associated with more rapid CKD progression, but whether lower bicarbonate levels also are associated with risk of incident estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m(2) and CKD progression among community-living persons with predominantly preserved kidney function is unknown. STUDY DESIGN: Longitudinal observational cohort study. SETTING & PARTICIPANTS: Well-functioning community-living elders aged 70-79 years at inception. PREDICTOR: Serum bicarbonate level measured at the time of collection by arterialized venous blood sample using an arterial blood gas analyzer. OUTCOMES: Change in eGFR over 7 years, and new eGFR < 60 mL/min/1.73 m(2) with a rate of loss of at least 1 mL/min/1.73 m(2) per year. MEASUREMENTS: Linear and logistic regressions were used to evaluate associations of baseline serum bicarbonate level with change in eGFR and incident eGFR < 60 mL/min/1.73 m(2). RESULTS: At baseline, mean eGFR was 84 ± 16 (SD)mL/min/1.73 m(2), and serum bicarbonate level was 25.2 ± 1.9 mmol/L. Compared with participants with higher bicarbonate concentrations (23.0-28.0 mmol/L), those with bicarbonate concentrations < 23 mmol/L (n = 85 [8%]) lost eGFR0.55 (95% CI, 0.13-0.97) mL/min/1.73 m(2) per year faster in models adjusted for demographics, CKD risk factors, baseline eGFR, and urine albumin-creatinine ratio. Among the 989 (92%) participants with baseline eGFRs > 60 mL/min/1.73 m(2), 252 (25%) developed incident eGFRs < 60 mL/min/1.73 m(2) at follow-up. Adjusting for the same covariates, participants with bicarbonate concentrations < 23 mmol/L had nearly 2-fold greater odds of incident eGFRs < 60 mL/min/1.73 m(2) (OR, 1.72; 95% CI, 0.97-3.07) compared with those with higher bicarbonate concentrations. LIMITATIONS: Only 2 measurements of kidney function separated by 7 years and loss to follow-up due to intervening mortality in this elderly population. CONCLUSIONS: Lower serum bicarbonate concentrations are associated independently with decline in eGFR and incident eGFR < 60 mL/min/1.73 m(2) in community-living older persons. If confirmed, serum bicarbonate levels may give insight into kidney tubule health in persons with preserved eGFRs and suggest a possible new target for intervention to prevent CKD development.

Low serum bicarbonate and kidney function decline: the Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND: Among populations with established chronic kidney disease (CKD), metabolic acidosis is associated with more rapid progression of kidney disease. The association of serum bicarbonate concentrations with early declines in kidney function is less clear. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 5,810 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) with a baseline estimated glomerular filtration rate (eGFR) > 60mL/min/1.73 m(2) using the CKD-EPI (CKD Epidemiology Collaboration) creatinine-cystatin C equation. PREDICTORS: Serum bicarbonate concentrations. OUTCOMES: Rapid kidney function decline (eGFR decline > 5% per year) and incident reduced eGFR (eGFR < 60mL/min/1.73 m(2) with minimum rate of eGFR loss of 1 mL/min/1.73 m(2) per year). RESULTS: Average bicarbonate concentration was 23.2 ± 1.8mEq/L. 1,730 (33%) participants had rapid kidney function decline, and 487 had incident reduced eGFR during follow-up. Each 1-SD lower baseline bicarbonate concentration was associated with 12% higher adjusted odds of rapid kidney function decline (95% CI, 6%-20%) and higher risk of incident reduced eGFR (adjusted incidence rate ratio, 1.11; 95% CI, 1.03-1.20) in models adjusting for demographics, baseline eGFR, albuminuria, and CKD risk factors. The OR for the associations of bicarbonate level < 21 mEq/L relative to 23-24 mEq/L was 1.35 (95% CI, 1.05-1.73) for rapid kidney function decline, and the incidence rate ratio was 1.16 (95% CI, 0.83-1.62) for incident reduced eGFR. LIMITATIONS: Cause of metabolic acidosis cannot be determined in this study. CONCLUSIONS: Lower serum bicarbonate concentrations are associated independently with rapid kidney function decline independent of eGFR or albuminuria in community-living persons with baseline eGFR > 60 mL/min/1.73 m(2). If confirmed, our findings suggest that metabolic acidosis may indicate either early kidney disease that is not captured by eGFR or albuminuria or may have a causal role in the development of eGFR < 60 mL/min/1.73 m(2).

Acute hepatitis C in an HIV-infected patient: a case report and review of literature.

With the decrease in transmission via transfusions and injection drug use, acute symptomatic hepatitis C is infrequently seen in developed countries. We report a case of a human immunodeficiency virus (HIV)-infected adult who presented with abdominal pain. His alanine aminotransferase was greater than sixty times the upper limit of normal without any evidence on examination of fulminant hepatic failure. His workup revealed an elevated hepatitis C viral level with a negative hepatitis C antibody. He was discharged once his liver function tests improved. As an outpatient, he had a recurrent bout of symptoms with an elevation of his alanine aminotransferase and hepatitis C viral levels that promoted anti-hepatitis C virus treatment. This case illustrates the importance of considering acute hepatitis C as a cause of acute hepatitis in HIV-infected men who have sex with men. While patients with acute symptomatic hepatitis C generally have a higher rate of spontaneous viral clearance compared to those with an insidious acute infection, most still progress to chronic hepatitis C infection, and patients with HIV coinfection carry a higher risk of progression to chronic disease.

Microbiological alterations in the conjunctiva of hot tub-soaking ophthalmologists (MACHO): a randomized double-blind clinical trial.

Background: To determine if there is a difference in the quantity of microbial flora of the conjunctiva in individuals practicing head submersion ("dunk") versus no head submersion ("no-dunk") during hot tub use. Methods: In this double-blind randomized clinical trial, healthy volunteers aged ≥ 18 years were recruited. Participants were randomized to head submersion versus no head submersion during a 15-minute hot tub soak. Study personnel, masked to the dunk or no-dunk group assignment, obtained conjunctival cultures before and immediately after hot tub use. De-identified specimens were submitted to the clinical microbiology laboratory for culture and analysis. The main outcome measure was the difference in the quantity of organisms cultured from the conjunctiva before and after hot tub exposure, as determined using a defined ordinal scale. A two-tailed Student's t-test was performed to compare the total microbial colony counts between the two arms. Simpson's diversity was used to measure the changes in organism diversity between the arms. Results: Of 36 enrolled subjects, 19 were randomly assigned to the dunk and 17 were assigned to the no-dunk groups. Water samples obtained from all hot tubs were culture negative. Eleven of 19 eyes (58%) from the dunk group and eight of 17 eyes (47%) from the no-dunk group had negative conjunctival bacterial cultures before and after hot tub exposure. However, six of 19 eyes (32%) and four of 17 eyes (24%) of the dunk and no-dunk groups, respectively, were culture-positive after, but not before hot tub exposure. The quantity of organisms before and after hot tub exposure was not significantly different between the two arms (P = 0.12). However, the dunk group only showed a small increase in the quantity of organisms after as compared to before hot tub use (P = 0.03). None of the samples from subjects or hot tubs were culture-positive for Acanthamoeba. Conclusions: Head submersion in a public hot tubs during a 15-minute soak does not appear to change conjunctival flora, as determined by culture plate yield, this does not eliminate the association between hot tub use and devastating and painful corneal blindness. Therefore, our recommendation is to remove contact lenses prior to hot tub use, avoid head submersion in a hot tub, and urgently seek ophthalmological help if any eye pain and/or decrease in vision is experienced after hot tub use.

Risk Factors for Return to the Operating Room after Resident-Performed Cataract Surgery.

OBJECTIVE: Investigate risk factors for unplanned return to the operating room after resident-performed cataract surgery. DESIGN: Retrospective case-control study. SETTING: Institutional. METHODS: Study population: All patients with reoperation within 90 days of resident-performed phacoemulsification were matched to four control eyes which had surgery within 30 days of the reoperation at the same institution. OBSERVATION PROCEDURE: Billing codes were used to identify all patients who underwent resident-performed intended phacoemulsification with intraocular lens placement from January 2005 to December 2010. MAIN OUTCOME MEASURES: Investigated risk factors for reoperation included cataract characteristics and preexisting ocular co-morbidities, including diabetic retinopathy, retinal detachment history, glaucoma, corneal pathology, and uveitis. Additional preoperative risk factors studied included resident training year, history of tamsulosin use, phacodonesis, pupillary dilation, presence of pseudoexfoliation, myopia, history of trauma, visual acuity, and monocular status. Intraoperative variables were the use of iris expansion devices, use of capsular stain, attending type, incision type, use of sutures, vitreous loss, anesthesia type, and phacoemulsification technique. RESULTS: There were 67 returns to the operating room (i.e., cases) over five years that were assigned to 268 control eyes. In preoperative multivariate analysis, phacoemulsification done by a first- or second-year resident (OR 3.2, 95% CI: 1.7-6.0, p < 0.001) was associated with an increased risk of reoperation. In postoperative multivariate analysis, only the use of the divide-and-conquer technique (OR 4.0, 95% CI:1.7-9.2, p = 0.001) was associated with an increased risk of reoperation. CONCLUSIONS: Phacoemulsification done by a junior resident or using the divide-and-conquer technique had the highest risk of reoperation.

Outcomes of the Boston Type I Keratoprosthesis as the Primary Penetrating Corneal Procedure.

PURPOSE: To report the outcomes of the Boston type I keratoprosthesis (KPro) as the primary penetrating corneal procedure. METHODS: In this retrospective review of all KPro procedures performed by 2 surgeons from May 1, 2004, to December 31, 2015, indications and outcomes were compared between KPros performed as the primary keratoplasty procedure (primary KPro) versus after failed keratoplasty (previous keratoplasty). RESULTS: A total of 262 KPros were implanted in 231 eyes, including 67 primary KPro procedures. The most common indications for primary KPros were corneal scarring/vascularization (43%), Stevens-Johnson syndrome (22%), and chemical/thermal injury (22%). Although preoperative corrected distance visual acuity (CDVA) was similar in the 2 groups (P = 0.36), a significantly higher proportion of the eyes in the primary KPro group had a CDVA ≥ 20/200 each of the first 4 years after surgery (all P ≤ 0.023). The most common postoperative complications in the primary KPro and previous keratoplasty groups were retroprosthetic membrane (40% vs. 51%, P = 0.15), persistent epithelial defect (37% vs. 24%, P = 0.05), and elevated intraocular pressure, which was the only complication significantly more common in either group (31% vs. 18%, P = 0.03). No difference in KPro retention was observed between the 2 groups (P = 0.63). CONCLUSIONS: In the setting of preexisting ocular comorbidities in which PK is associated with poor outcomes and KPros have been associated with an increased incidence of postoperative complications, primary KPro is associated with significantly greater % of eyes with CDVA ≥ 20/200 in the first 4 years. However, given a significantly higher incidence of postoperative intraocular pressure elevation in these eyes, longer follow-up is needed to determine whether the difference in CDVA is maintained.

Late-onset, snowstorm-like appearance of calcium deposits coating a poly(methyl methacrylate) posterior chamber intraocular lens.

UNLABELLED: An 81-year-old man developed decreased vision associated with diffuse precipitates on his poly(methyl methacrylate) (PMMA) posterior chamber intraocular lens (IOL), on his corneal endothelium, and in his anterior chamber approximately 35 years after IOL implantation. Slitlamp evaluation showed diffuse white material on the surface of the IOL, white precipitates on the corneal endothelium, and visible debris in the anterior chamber. The patient had IOL exchange, and pathological analysis showed numerous calcium deposits within the Soemmerring ring that diffusely spread to the anterior surface of the PMMA IOL. This case of diffuse calcium precipitates on the IOL and the corneal endothelium and in the anterior chamber 35 years after implantation shows that even long after IOL implantation, lens epithelium proliferation and metabolism can result in sequestered material that can be released many years later. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nurses, trainees, and patients.

BACKGROUND: The field of patient safety grapples with the tension between a "no-blame" systems approach and the need to hold providers accountable for substandard performance. Attitudes of clinicians and patients regarding methods of promoting adherence to safety practices have not been described. METHODS: We surveyed attending and resident physicians in the University of California, San Francisco (UCSF) Department of Medicine, nurses and inpatients at the UCSF Medical Center, and UCSF medical students regarding attitudes toward violations of 3 safety protocols: hand hygiene, fall risk assessment, and preoperative time-out. RESULTS: Responses to protocol lapses were grouped into 3 categories: feedback (universally endorsed and thus excluded from the analysis), public reporting, and penalty (fines, suspension, firing). We examined group differences regarding whether public reporting and penalties were ever appropriate and the number of transgressions at which public reporting and penalties were favored. Respondents favored both public reporting and penalties more frequently for not conducting a preoperative time-out or fall risk assessment than for hand-hygiene lapses (public reporting: time-out, odds ratio [OR]: 2.82 [95% confidence interval {CI}: 2.03-3.91]; fall, OR: 1.47 [95% CI: 1.09-1.98]. Penalty: time-out, OR: 4.29 [95% CI: 2.97-6.20]; fall, OR: 1.74 [95% CI: 1.27-2.37]). Penalties were endorsed more frequently than public reporting for all groups and scenarios. Attending physicians and patients expressed similar attitudes regarding public reporting and penalties, but patients favored penalties after significantly fewer transgressions (P < 0.05). CONCLUSION: After a decade emphasizing no-blame responses to patient safety hazards, both healthcare providers and patients now believe clinicians should be held accountable for following basic safety protocols.

Comparisons of creatinine and cystatin C for detection of kidney disease and prediction of all-cause mortality in HIV-infected women.

BACKGROUND: Cystatin C could improve chronic kidney disease (CKD) classification in HIV-infected women relative to serum creatinine. DESIGN: Retrospective cohort analysis. METHODS: Cystatin C and creatinine were measured from specimens taken and stored during the 1999-2000 examination among 908 HIV-infected participants in the Women's Interagency HIV study (WIHS). Mean follow-up was 10.2 years. Predictors of differential glomerular filtration rate (GFR) estimates were evaluated with multivariable linear regression. The associations of baseline categories (<60, 60-90, and >90 ml/min per 1.73 m) of creatinine estimated GFR (eGFRcr), cystatin C eGFR (eGFRcys), and combined creatinine-cystatin C eGFR (eGFRcr-cys) with all-cause mortality were evaluated using multivariable Cox regression. The net reclassification index (NRI) was calculated to evaluate the effect of cystatin C on reclassification of CKD staging. RESULTS: CKD risk factors were associated with lower eGFRcys and eGFRcr-cys values compared with eGFRcr. Relative to eGFR more than 90, the eGFR less than 60 category by eGFRcys (Adjusted hazard ratio: 2.56; 95% confidence interval: 1.63-4.02), eGFRcr-cys (3.11; 1.94-5.00), and eGFRcr (2.34; 1.44-3.79) was associated with increased mortality risk. However, the eGFR 60-90 category was associated with increased mortality risk for eGFRcys (1.80; 1.28-2.53) and eGFRcr-cys (1.91; 1.38-2.66) but not eGFRcr (1.20; 0.85-1.67). The overall NRI for mortality was 26% when reclassifying from eGFRcr to eGFRcys (P < 0.001) and was 20% when reclassifying from eGFRcr to eGFRcr-cys (P < 0.001). CONCLUSION: The addition of cystatin C may improve mortality risk prediction by stages of kidney function relative to creatinine. CKD risk factors are associated with an overestimate of GFR by serum creatinine relative to cystatin C.

Can healthcare go from good to great?

Healthcare's improvement efforts have focused on the point of care, targeting specific processes such as preventing central line infections, while paying relatively less attention to the larger issues of organizational structure and leadership. Interestingly, the business community has long recognized that poor management and structure can thwart improvement efforts. Perhaps the corporate world's best-known study of these issues is found in the book Good to Great, which identifies top-performing corporations, compares them to carefully selected organizations that failed to achieve similar levels of performance, and gleans lessons from these analyses. In this article, we analyze the feasibility of carefully applying Good to Great's methods for analyzing organizational structure and leadership to healthcare. While a few studies in healthcare have come close to emulating Good to Great's methodology, none have matched its rigor. These shortcomings highlight key information and measurement gaps that must be addressed to facilitate unbiased, rigorous studies of the organizational and leadership predictors of institutional excellence in healthcare.