Alameda Health System

OBJECTIVE: B cells are likely to contribute to the pathogenesis of systemic lupus erythematosus (SLE), and rituximab induces depletion of B cells. The Exploratory Phase II/III SLE Evaluation of Rituximab (EXPLORER) trial tested the efficacy and safety of rituximab versus placebo in patients with moderately-to-severely active extrarenal SLE. METHODS: Patients entered with >or=1 British Isles Lupus Assessment Group (BILAG) A score or >or=2 BILAG B scores despite background immunosuppressant therapy, which was continued during the trial. Prednisone was added and subsequently tapered. Patients were randomized at a ratio of 2:1 to receive rituximab (1,000 mg) or placebo on days 1, 15, 168, and 182. RESULTS: In the intent-to-treat analysis of 257 patients, background treatment was evenly distributed among azathioprine, mycophenolate mofetil, and methotrexate. Fifty-three percent of the patients had >or=1 BILAG A score at entry, and 57% of the patients were categorized as being steroid dependent. No differences were observed between placebo and rituximab in the primary and secondary efficacy end points, including the BILAG-defined response, in terms of both area under the curve and landmark analyses. A beneficial effect of rituximab on the primary end point was observed in the African American and Hispanic subgroups. Safety and tolerability were similar in patients receiving placebo and those receiving rituximab. CONCLUSION: The EXPLORER trial enrolled patients with moderately-to-severely active SLE and used aggressive background treatment and sensitive cutoffs for nonresponse. No differences were noted between placebo and rituximab in the primary and secondary end points. Further evaluation of patient subsets, biomarkers, and exploratory outcome models may improve the design of future SLE clinical trials.

The metabolic syndrome contributes to cardiovascular morbidity and mortality. 1-4Data from the National Health and Nutrition Examination Survey (NHANES) 1999-2006 reported a metabolic syndrome prevalence of 34%. 5 Understanding updated prevalence trends may be important given the potential effect of the metabolic syndrome and its associated health complications on the aging US population.We investigated trends in the prevalence of the metabolic syndrome through 2012.a Trend comparisons from year ranges listed to 2011-2012.

This study uses US national survey data to characterize trends in the prevalence of metabolic syndrome among adults in the US between 2011 and 2016.

Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. In the new paradigm, a 3-step approach is used. First, the patient is verbally engaged; then a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state. Verbal de-escalation is usually the key to engaging the patient and helping him become an active partner in his evaluation and treatment; although, we also recognize that in some cases nonverbal approaches, such as voluntary medication and environment planning, are also important. When working with an agitated patient, there are 4 main objectives: (1) ensure the safety of the patient, staff, and others in the area; (2) help the patient manage his emotions and distress and maintain or regain control of his behavior; (3) avoid the use of restraint when at all possible; and (4) avoid coercive interventions that escalate agitation. The authors detail the proper foundations for appropriate training for de-escalation and provide intervention guidelines, using the "10 domains of de-escalation."

Triage of mass casualties in situations in which patients must remain on-scene for prolonged periods of time, such as after a catastrophic earthquake, differs from traditional triage. Often there are multiple scenes (sectors), and the infrastructure is damaged. Available medical resources are limited, and the time to definitive care is uncertain. Early evacuation is not possible, and local initial responders cannot expect significant outside assistance for at least 49-72 hours. Current triage systems are based either on a shorter time to definitive care or on a longer time to initial triage. The Medical Disaster Response (MDR) project deals with the scenario in which specially trained, local health-care providers evaluate patients immediately after the event, but cannot evacuate patients to definitive care. For this type of scenario, a dynamic triage methodology was developed that permits the triage process to evolve over hours or even days, thereby maximizing patient survival and resulting in a more efficient use of resources. This MDR system incorporates a modified version of "Simple Triage and Rapid Treatment" (START) that substitutes radial pulse for capillary refill, coupled with a system of secondary triage termed, "Secondary Assessment of Victim Endpoint" (SAVE). The SAVE triage was developed to direct limited resources to the subgroup of patients expected to benefit most from their use. The SAVE assesses survivability of patients with various injuries and, on the basis of trauma statistics, uses this information to describe the relationship between expected benefits and resources consumed. Because early transport to an intact medical system is unavailable, this information guides treatment priorities in the field to a level beyond the scope of the START methodology. Pre-existing disease and age are factored into the triage decisions. An elderly patient with burns to 70% of body surface area is unsalvageable under austere field conditions and would require the use of significant medical resources-both personnel and equipment-and would be triaged to an "expectant area." Conversely, a young adult with a Glasgow Coma Scale score of 12 who requires only airway maintenance would use few resources and would have a reasonable chance for survival with the interventions available in the field, and would be triaged to a "treatment" area. The START and SAVE triage techniques are used in situations in which triage is dynamic, occurs over many hours to days, and only limited, austere, field, advanced life support equipment is readily available. The MDR-SAVE methodology is the first systematic attempt to use triage as a tool to maximize patient benefit in the immediate aftermath of a catastrophic disaster.

During the past 20 years, natural disasters have claimed more than 3 million lives worldwide, affected at least 800 million people, and resulted in property damage exceeding $50 billion.1 The recent earthquake of magnitude 7.2 in Kobe, Japan, left more than 5000 people dead. In the United States, the great earthquake along the New Madrid fault of the Mississippi Valley in 1812 is said to have rung church bells in Boston and caused the Mississippi River to flow backward for three days.2,3 If a magnitude 8.3 earthquake were to take place along the San Andreas fault, it is estimated . . .

BACKGROUND: Despite efforts toward the earlier detection and prevention of skin cancer, the prevalence of skin cancers continues to increase. Identifying trends in skin cancer burdens among populations can lead to impactful and sustainable interventions. METHODS: We assessed the global trends in skin cancer from 1990 to 2017 in 195 countries worldwide through the Global Burden of Disease Study (GBD) 2017 database. RESULTS: < .05). CONCLUSION: The incidence, prevalence, and DALYs of skin cancers are increasing disproportionately among different demographic groups. As a worldwide epidemiological assessment, the GBD 2017 provides frequently updated measures of the skin cancer burden, which may help to direct resources and allocate funding to close the gap in global skin cancer disparities.

BACKGROUND: Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions. METHODS: An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items. RESULTS: Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic. CONCLUSIONS: Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.

Using the United Network for

Importance: One factor associated with the rapidly increasing clinical and economic burden of chronic liver disease (CLD) is inpatient health care utilization. Objective: To understand trends in the hospitalization burden of CLD in the US. Design, Setting, and Participants: This cross-sectional study of hospitalized adults in the US used data from the National Inpatient Sample from 2012 to 2016 on adult CLD-related hospitalizations. Data were analyzed from June to October 2019. Main Outcomes and Measures: Hospitalizations identified using a comprehensive review of CLD-specific International Classification of Diseases, Ninth Revision, Clinical Modification and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes. Survey-weighted annual trends in national estimates of CLD-related hospitalizations, in-hospital mortality, and hospitalization costs, stratified by demographic and clinical characteristics. Results: This study included 1 016 743 CLD-related hospitalizations (mean [SD] patient age, 57.4 [14.4] years; 582 197 [57.3%] male; 633 082 [62.3%] white). From 2012 to 2016, the rate of CLD-related hospitalizations per 100 000 hospitalizations increased from 3056 (95% CI, 3042-3069) to 3757 (95% CI, 3742-3772), and total inpatient hospitalization costs increased from $14.9 billion (95% CI, $13.9 billion to $15.9 billion) to $18.8 billion (95% CI, $17.6 billion to $20.0 billion). Mean (SD) patient age increased (56.8 [14.2] years in 2012 to 57.8 [14.6] years in 2016) and, subsequently, the proportion with Medicare also increased (41.7% [95% CI, 41.1%-42.2%] to 43.6% [95% CI, 43.1%-44.1%]) (P for trend < .001 for both). The proportion of hospitalizations of patients with hepatitis C virus was similar throughout the period of study (31.6% [95% CI, 31.3%-31.9%]), and the proportion with alcoholic cirrhosis and nonalcoholic fatty liver disease showed increases. The mortality rate was higher among hospitalizations with alcoholic cirrhosis (11.9% [95% CI, 11.7%-12.0%]) compared with other etiologies. Presence of hepatocellular carcinoma was also associated with a high mortality rate (9.8% [95% CI, 9.5%-10.1%]). Cost burden increased across all etiologies, with a higher total cost burden among hospitalizations with alcoholic cirrhosis ($22.7 billion [95% CI, $22.1 billion to $23.2 billion]) or hepatitis C virus ($22.6 billion [95% CI, $22.1 billion to $23.2 billion]). Presence of cirrhosis, complications of cirrhosis, and comorbidities added to the CLD burden. Conclusions and Relevance: Over the study period, the total estimated national hospitalization costs in patients with CLD reached $81.1 billion. The inpatient CLD burden in the US is likely increasing because of an aging CLD population with increases in concomitant comorbid conditions.

Colorectal cancer (CRC) is a leading cause of cancer mortality worldwide. CRC incidence and mortality can be reduced through screening. However, in the United States, screening participation remains suboptimal, particularly among underserved populations such as the uninsured, recent immigrants, and racial/ethnic minority groups. Increasing screening rates among underserved populations will reduce the US burden of CRC. In this commentary focusing on underserved populations, we highlight the public health impact of CRC screening, list key challenges to screening the underserved, and review promising approaches to boost screening rates. We identify four key policy and research priorities to increase screening among underserved populations: 1) actively promote the message, "the best test is the one that gets done"; 2) develop and implement methods to identify unscreened individuals within underserved population groups for screening interventions; 3) develop and implement approaches for organized screening delivery; and 4) fund and enhance programs and policies that provide access to screening, diagnostic follow-up, and CRC treatment for underserved populations. This commentary represents the consensus of a diverse group of experts in cancer control and prevention, epidemiology, gastroenterology, and primary care from across the country who formed the Coalition to Boost Screening among the Underserved in the United States. The group was organized and held its first annual working group meeting in conjunction with the World Endoscopy Organization's annual Colorectal Cancer Screening Committee meeting during Digestive Disease Week 2012 in San Diego, California.

OBJECTIVES: Emergency department (ED) bedside echocardiography may offer useful information on cardiac function and volume status. The authors evaluated the accuracy of emergency physician (EP) performance of echocardiography in the assessment of left ventricular ejection fraction (LVEF) and central venous pressure (CVP). METHODS: The authors conducted a cross-sectional observational study at an urban teaching ED, involving a convenience sample of patients presenting to the ED between September 2000 and February 2001. Level III-credentialed EP sonographers who had undergone a three-hour training session in limited echocardiography, focusing on LVEF and CVP measurement, performed echocardiograms. Vital signs and indication for echocardiography were documented on a study data sheet. LVEF was rated as poor (<30%), moderate (30%-55%), or normal (>55%) and an absolute percentage. Central venous pressure categories included low (<5 cm), moderate (5-10 cm), and high (>10 cm). Formal echocardiograms were obtained within a four-hour window on all patients and interpreted by a staff cardiologist. Correlation analysis was performed using the kappa correlation coefficient for LVEF and CVP categories and a Pearson correlation coefficient for LVEF measurement. RESULTS: A total of 115 patients were assessed for LVEF, and 94 patients had complete information for CVP. Indications for echocardiography included chest pain (45.1%), congestive heart failure (38.1%), dyspnea (5.7%), and endocarditis (10.6%). Results showed a LVEF correlation of r(2) = 0.712 with 86.1% overall agreement. Subgroup analysis revealed the highest agreement (92.3%) between EP and formal echocardiograms within the normal LVEF category, followed by 70.4% agreement in the poor LVEF category and 47.8% in the moderate LVEF category. Central venous pressure measurements resulted in 70.2% overall raw agreement between EP and formal echocardiograms. Subgroup analysis revealed the highest agreement (83.3%) within the high CVP category followed by 66.6% in the moderate and 20% in the low categories. CONCLUSIONS: Experienced EP sonographers with a small amount of focused additional training in limited bedside echocardiography can assess LVEF accurately in the ED.

Many hospitalists incorporate point-of-care ultrasound (POCUS) into their daily practice to answer specific diagnostic questions or to guide performance of invasive bedside procedures. However, standards for hospitalists in POCUS training and assessment are not yet established. Most internal medicine residency training programs, the major pipeline for incoming hospitalists, have only recently begun to incorporate POCUS in their curricula. The purpose of this document is to inform a broad audience on what POCUS is and how hospitalists are using it. This document is intended to provide guidance for the hospitalists who use POCUS and administrators who oversee its use. We discuss POCUS 1) applications, 2) training, 3) assessments, and 4) program management. Practicing hospitalists must continue to collaborate with their local credentialing bodies to outline requirements for POCUS use. Hospitalists should be integrally involved in decision-making processes surrounding POCUS program management.

PURPOSE: Medical students have higher rates of depression and psychologic distress than the general population, which may negatively impact academic performance and professional conduct. This study assessed whether 10-20 min of daily mindfulness meditation for 30 days, using a mobile phone application, could decrease perceived stress and improve well-being for medical students. METHODS: Eighty-eight medical students were stratified by class year and randomized to either intervention or control groups to use the mobile application Headspace, an audio-guided mindfulness meditation program, for 30 days. All participants completed the Perceived Stress Scale (PSS), Five-Facet Mindfulness Questionnaire (FFMQ), and General Well-Being Schedule (GWBS) at baseline (T1), 30 days (T2), and 60 days (T3). Repeated measures analysis of variance (rANOVA) was conducted for intervention versus control groups across T1, T2, and T3 to examine differences in stress, mindfulness, and well-being. RESULTS: There was a significant interaction between time and treatment group for perceived stress and well-being. Perceived stress significantly decreased for the intervention group from T1 to T3 (F[2,142] = 3.98, p < 0.05). General well-being significantly increased for the intervention group compared to the control group from T1 to T2, and the increase was sustained through T3 (F[2,144] = 3.36, p < 0.05). CONCLUSIONS: These results highlight that a mobile audio-guided mindfulness meditation program is an effective means to decrease perceived stress in medical students, which may have implications on patient care. Integrating mindfulness training into medical school curricula for management of school- and work-related stress may lead to fewer negative physician outcomes (e.g., burnout, anxiety, and depression) and improved physician and patient outcomes. This has implications for a broad group of therapists and healthcare providers, ultimately improving quality of healing and patient care.

Esophageal symptoms are common and may indicate the presence of gastroesophageal reflux disease (GERD), structural processes, motor dysfunction, behavioral conditions, or functional disorders. Esophageal physiologic tests are often performed when initial endoscopic evaluation is unrevealing, especially when symptoms persist despite empiric management. Commonly used esophageal physiologic tests include esophageal manometry, ambulatory reflux monitoring, and barium esophagram. Functional lumen imaging probe (FLIP) has recently been approved for the evaluation of esophageal pressure and dimensions using volumetric distension of a catheter-mounted balloon and as an adjunctive test for the evaluation of symptoms suggestive of motor dysfunction. Targeted utilization of esophageal physiologic tests can lead to definitive diagnosis of esophageal disorders but can also help rule out organic disorders while making a diagnosis of functional esophageal disorders. Esophageal physiologic tests can evaluate obstructive symptoms (dysphagia and regurgitation), typical and atypical GERD symptoms, and behavioral symptoms (belching and rumination). Certain parameters from esophageal physiologic tests can help guide the management of GERD and predict outcomes. In this ACG clinical guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to describe performance characteristics and clinical value of esophageal physiologic tests and provide recommendations for their utilization in routine clinical practice.

[West J Emerg Med. 2012;13(1):1–2.]

BACKGROUND: Over the last decade, utilization of ultrasound technology by non-radiologist physicians has grown. Recent advances in affordability, durability, and portability have brought ultrasound to the forefront as a sustainable and high impact technology for use in developing world clinical settings as well. However, ultrasound's impact on patient management plans, program sustainability, and which ultrasound applications are useful in this setting has not been well studied. METHODS: Ultrasound services were introduced at two rural Rwandan district hospitals affiliated with Partners in Health, a US nongovernmental organization. Data sheets for each ultrasound scan performed during routine clinical care were collected and analyzed to determine patient demographics, which ultrasound applications were most frequently used, and whether the use of the ultrasound changed patient management plans. Ultrasound scans performed by the local physicians during the post-training period were reviewed for accuracy of interpretation and image quality by an ultrasound fellowship trained emergency medicine physician from the United States who was blinded to the original interpretation. RESULTS: Adult women appeared to benefit most from the presence of ultrasound services. Of the 345 scans performed during the study period, obstetrical scanning was the most frequently used application. Evaluation of gestational age, fetal head position, and placental positioning were the most common findings. However, other applications used included abdominal, cardiac, renal, pleural, procedural guidance, and vascular ultrasounds.Ultrasound changed patient management plans in 43% of total patients scanned. The most common change was to plan a surgical procedure. The ultrasound program appears sustainable; local staff performed 245 ultrasound scans in the 11 weeks after the departure of the ultrasound instructor. Post-training scan review showed the concordance rate of interpretation between the Rwandese physicians and the ultrasound-trained quality review physicians was 96%. CONCLUSION: We suggest ultrasound is a useful modality that particularly benefits women's health and obstetrical care in the developing world. Ultrasound services significantly impact patient management plans especially with regards to potential surgical interventions. After an initial training period, it appears that an ultrasound program led by local health care providers is sustainable and lead to accurate diagnoses in a rural international setting.

BACKGROUND: Risk factors and timing associated with disease progression and mortality in nonalcoholic fatty liver disease (NAFLD) are poorly understood. AIMS: To evaluate the impact of disease severity, demographics and comorbidities on risk of mortality and time to progression in a large, real-world cohort of diagnosed NAFLD patients. METHODS: Claims data from a 20% Medicare representative sample between 2007 and 2015 were analysed retrospectively. Adults were categorised into disease severity groups: NAFLD/nonalcoholic steatohepatitis (NASH) alone, compensated cirrhosis, decompensated cirrhosis, liver transplant or hepatocellular carcinoma. Cumulative incidence of mortality and disease progression were calculated for each group and multivariate analyses performed adjusting for demographics, comorbidities and disease severity. RESULTS: A total of 10 826 456, patients were assessed and the prevalence of NAFLD was 5.7% (N = 621 253). Among patients with NAFLD, 71.1% had NAFLD/NASH alone and 28.9% had NAFLD cirrhosis. Overall, 85.5% of patients had hypertension, 84.1% dyslipidemia, 68.7% had cardiovascular disease and 55.5% diabetes. The cumulative risk of progression of NAFLD to cirrhosis, and compensated cirrhosis to decompensated cirrhosis was 39% and 45%, respectively, over 8 years of follow-up. The independent predictors of progression included cardiovascular disease, renal impairment, dyslipidemia and diabetes. The cumulative risk of mortality for NAFLD, NAFLD cirrhosis, decompensated cirrhosis and hepatocellular carcinoma was 12.6%, 31.1%, 51.4% and 76.2%, respectively. CONCLUSIONS: The present report (a) demonstrates that NAFLD is grossly underdiagnosed in real-world clinical settings and (b) provides new evidence on the progression rates of NAFLD and risk factors of mortality across the spectrum of severity of NAFLD and cirrhosis.

Establishing the phylogeny of fungi and protists often has proved difficult owing to the simple morphologies and convergent characters in these organisms. We used DNA sequences of nuclear small-subunit ribosomal RNA genes to determine phylogenetic relationships among three major classes of organisms considered to be fungi--Basidiomycetes, Ascomycetes and Chytridiomycetes--and to assess the taxonomic position of Neocallimastix, an economically important anaerobic rumen microorganism whose classification is controversial. The Basidiomycetes and Ascomycetes, two classes of nonflagellated fungi, are the most closely related taxa. Chytridiomycetes, though bearing flagella, group with these higher fungi rather than with the protists. Neocallimastix, a eukaryote lacking mitochondria and variously classified as a protist or as a fungus, shows closest molecular affinities with the Chytridiomycete fungi in the order Spizellomycetales.

Stroke is a devastating complication of sickle cell anemia (SCA), affecting up to 30% of children with the disease. Despite the relative frequency of stroke in SCA, few predictors of risk exist. Because stroke in SCA is likely a multifactorial disease, analysis of the combined effect of multiple genetic variants may prove more successful than evaluation of individual candidate genes. We genotyped 230 children with SCA for 104 polymorphisms among 65 candidate vascular genes to identify risk associations with stroke. Patients were phenotyped based on magnetic resonance imaging/angiography (MRI/MRA) findings into large-vessel (LV) versus small-vessel (SV) disease stroke subgroups. Specific polymorphisms in the IL4R 503, TNF (-308), and ADRB2 27 genes were independently associated with stroke susceptibility in the LV stroke subgroup, while variants in the VCAM1 (-1594) and LDLR NcoI genes were associated with SV stroke risk. The combination of TNF (-308)GG homozygosity and the IL4R 503P variant carrier status was associated with a particularly strong predisposition to LV stroke (odds ratio [OR] = 5.5; 95% confidence interval [CI] = 2.3-13.1). We show that several candidate genes may play a role in predisposition to specific stroke subtypes in children with SCA. If confirmed, these results provide a basis for population screening and targeted intervention to prevent stroke in SCA.