Highland Hospital

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.

From the Surgery Service and the Clinical Investigation Center of the Naval Hospital, Oakland, Calif.

BACKGROUND: Most sickle cell anemia patients undergo transfusion therapy to prevent complications. The Stroke Prevention Trial in Sickle Cell Anemia showed that transfusion therapy is effective in the primary prevention of stroke. Despite its efficacy, transfusion therapy is limited by alloimmunization. The purpose of this study was to determine if a multicenter trial could implement a transfusion program utilizing phenotypically matched blood to reduce alloimmunization. STUDY DESIGN AND METHODS: One hundred thirty children underwent RBC phenotyping and antibody screening with review of blood bank records. The protocol required use of WBC-reduced RBCs, which were matched for E, C, and Kell. Monthly alloantibody testing and review of transfusion forms were performed to determine compliance and the occurrence of any adverse events. RESULTS: Patient RBCs expressed a low frequency of Kell (2%), E (20%), and C (25%) antigens. Sixty-one patients received 1830 units. Ninety-seven percent of all units were WBC reduced. Only 29 units were inadvertently not matched for E, C, and Kell. Five patients (8%) developed a clinically significant alloantibody. Four developed a single antibody to E or Kell. Three patients (5%) developed a warm autoantibody. There were 11 transfusion reactions and 8 transfusion-associated events. Transfusion reactions included 6 febrile reactions (0.33%/unit), 3 allergic (0.16%/unit), and 2 hemolytic (0.11%/unit). Associated events included 4 episodes of hypertension (0.22%/unit), 3 crises (0.16%/unit), and 1 transient ischemic attack (0.05%/unit). CONCLUSION: This is the first multicenter study to show that extended RBC phenotyping can be implemented nationwide. Compared to studies, the alloimmunization rate dropped from 3 percent to 0.5 percent per unit, and hemolytic transfusion reactions dropped by 90 percent. It is recommended that all transfused sickle cell anemia patients be antigen matched for E, C, and Kell. Patients should be closely monitored during transfusions to avoid preventable risks.

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.

Introduction: Research on disparities in health and health care has demonstrated that social, economic, and political factors are key drivers of poor health outcomes. Yet the role of such structural forces on health and health care has been incorporated unevenly into medical training. The framework of structural competency offers a paradigm for training health professionals to recognize and respond to the impact of upstream, structural factors on patient health and health care. Methods: We report on a brief, interprofessional structural competency curriculum implemented in 32 distinct instances between 2015 and 2017 throughout the San Francisco Bay Area. In consultation with medical and interprofessional education experts, we developed open-ended, written-response surveys to qualitatively evaluate this curriculum's impact on participants. Qualitative data from 15 iterations were analyzed via directed thematic analysis, coding language, and concepts to identify key themes. Results: Three core themes emerged from analysis of participants' comments. First, participants valued the curriculum's focus on the application of the structural competency framework in real-world clinical, community, and policy contexts. Second, participants with clinical experience (residents, fellows, and faculty) reported that the curriculum helped them reframe how they thought about patients. Third, participants reported feeling reconnected to their original motivations for entering the health professions. Discussion: This structural competency curriculum fills a gap in health professional education by equipping learners to understand and respond to the role that social, economic, and political structural factors play in patient and community health.

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.

Unintended incidental durotomy is not an infrequent complication of spinal surgery (incidence, 0.3-13% reported). Although prompt repair is advocated, little has been written regarding any consequences of primarily repaired durotomies on long-term patient outcome. A retrospective review of 450 patients undergoing lumbar spine surgery revealed 17 cases (4%) of incidental durotomy, recognized intraoperatively and repaired primarily. These patients were evaluated at long-term follow-up (mean, 25.1 months); and their results were compared with controls matched for age, diagnosis, procedure, and length of follow-up. No differences of statistical significance could be identified in comparing the outcomes of the two groups. Incidental durotomy, when recognized and repaired intraoperatively, does not increase perioperative morbidity or compromise final result.

BACKGROUND: Use of social media has become widespread across the United States. Although businesses have invested in social media to engage consumers and promote products, less is known about the extent to which hospitals are using social media to interact with patients and promote health. OBJECTIVE: The aim was to investigate the relationship between hospital social media extent of adoption and utilization relative to hospital characteristics. METHODS: We conducted a cross-sectional review of hospital-related activity on 4 social media platforms: Facebook, Twitter, Yelp, and Foursquare. All US hospitals were included that reported complete data for the Centers for Medicare and Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Systems survey and the American Hospital Association Annual Survey. We reviewed hospital social media webpages to determine the extent of adoption relative to hospital characteristics, including geographic region, urban designation, bed size, ownership type, and teaching status. Social media utilization was estimated from user activity specific to each social media platform, including number of Facebook likes, Twitter followers, Foursquare check-ins, and Yelp reviews. RESULTS: Adoption of social media varied across hospitals with 94.41% (3351/3371) having a Facebook page and 50.82% (1713/3371) having a Twitter account. A majority of hospitals had a Yelp page (99.14%, 3342/3371) and almost all hospitals had check-ins on Foursquare (99.41%, 3351/3371). Large, urban, private nonprofit, and teaching hospitals were more likely to have higher utilization of these accounts. CONCLUSIONS: Although most hospitals adopted at least one social media platform, utilization of social media varied according to several hospital characteristics. This preliminary investigation of social media adoption and utilization among US hospitals provides the framework for future studies investigating the effect of social media on patient outcomes, including links between social media use and the quality of hospital care and services.

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.

UNLABELLED: In this research, we sought to test the hypothesis that the AccuTouch Flexible Bronchoscopy Simulator (Simulator) is an effective way to teach clinicians the psychomotor skills necessary to use the fiberoptic bronchoscope as an instrument for intubating the trachea of a pediatric patient. Pediatric residents with no prior experience in fiberoptic bronchoscopy were studied. Residents performed fiberoptic intubation on children undergoing general anesthesia. Tapes of these intubations were analyzed for: time to visualization of the carina, and number and time that the bronchoscope tip hit the mucosa. Residents were then trained on the Simulator. Performance of fiberoptic intubation on a subsequent child was compared. Training on the Simulator was the only instruction that the residents received between the two cases. A control group of residents performed two consecutive intubations without training on the Simulator between cases. Residents studied an average of 17 cases, and spent 39 min on the Simulator. Performance was markedly improved after the Simulator. Time to completion of successful intubation with a bronchoscope was reduced from 5.15 to 0.88 min (P < 0.001). The number of times that the tip of the bronchoscope hit the mucosa was reduced from 21.4 to 3.0 (P < 0.001). The amount of time that the resident spent viewing the mucosa decreased from 2.24 to 0.19 min (P < 0.001). The percent of time viewing the channel of the airway increased from 58.5% to 80.4% (P = 0.004). This bronchoscopy simulator was very effective in teaching residents the psychomotor skills necessary for fiberoptic intubation. Significant improvement was seen in time to completion of endotracheal intubation, as well as other performance indicators. IMPLICATIONS: This research showed that the AccuTouch Bronchoscopy Simulator is an effective way to teach the psychomotor skills necessary to intubate the trachea of patients using a fiberoptic bronchoscope. The residents that practiced on the Simulator dramatically improved their skills compared with a control group of residents.

Importance: Given the risks of postoperative morbidity and its consequent economic burden and impairment to patients undergoing colon resection, evaluating risk factors associated with complications will allow risk stratification and the targeting of supportive interventions. Evaluation of muscle characteristics is an emerging area for improving preoperative risk stratification. Objective: To examine the associations of muscle characteristics with postoperative complications, length of hospital stay (LOS), readmission, and mortality in patients with colon cancer. Design, Setting, and Participants: This population-based retrospective cohort study was conducted among 1630 patients who received a diagnosis of stage I to III colon cancer from January 2006 to December 2011 at Kaiser Permanente Northern California, an integrated health care system. Preliminary data analysis started in 2017. Because major complication data were collected between 2018 and 2019, the final analysis using the current cohort was conducted between 2019 and 2020. Exposures: Low skeletal muscle index (SMI) and/or low skeletal muscle radiodensity (SMD) levels were assessed using preoperative computerized tomography images. Main Outcomes and Measures: Length of stay, any complication (≥1 predefined complications) or major complications (Clavien-Dindo classification score ≥3), 30-day mortality and readmission up to 30 days postdischarge, and overall mortality. Results: The mean (SD) age at diagnosis was 64.0 (11.3) years and 906 (55.6%) were women. Patients with low SMI or low SMD were more likely to remain hospitalized 7 days or longer after surgery (odds ratio [OR], 1.33; 95% CI, 1.05-1.68; OR, 1.39; 95% CI, 1.05-1.84, respectively) and had higher risks of overall mortality (hazard ratio, 1.40; 95% CI, 1.13-1.74; hazard ratio, 1.44; 95% CI, 1.12-1.85, respectively). Additionally, patients with low SMI were more likely to have 1 or more postsurgical complications (OR, 1.31; 95% CI, 1.04-1.65) and had higher risk of 30-day mortality (OR, 4.85; 95% CI, 1.23-19.15). Low SMD was associated with higher odds of having major complications (OR, 2.41; 95% CI, 1.44-4.04). Conclusions and Relevance: Low SMI and low SMD were associated with longer LOS, higher risk of postsurgical complications, and short-term and long-term mortality. Research should evaluate whether targeting potentially modifiable factors preoperatively, such as preserving muscle mass, could reverse the observed negative associations with postoperative outcomes.

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.

The results of nonoperative treatment of 72 patients with complete anterior cruciate ligament (ACL) tears, documented by examination under anesthesia and arthroscopy, were evaluated. All patients had an acute injury with hemarthrosis in a previously normal knee. Patients having meniscal repair were excluded as were those with collateral or posterior cruciate ligament tears or associated fractures. Treatment in all cases consisted of a standard protocol of early rehabilitation and bracing. A detailed rating of symptoms and function was performed at an average of 38 months postinjury (range, eight to 84 months). Overall results were 11% excellent, 20% good, 15% fair, and 54% poor. Thirty-five percent had ACL reconstruction during the follow-up period. Results indicate that young adults who return to a vocation requiring strenuous physical activity frequently can expect unsatisfactory results after nonoperative treatment of an acute complete tear of the ACL.

This national survey study uses National Health and Nutrition Examination Survey (NHANES) data to estimate the prevalence of alcoholic fatty liver disease (AFLD) overall and with stage 2 or greater and stage 3 or greater fibrosis among US adults from 2001 to 2016.

OBJECTIVES: To characterize the reasons ambulatory patients use hospital emergency departments (EDs) for outpatient care and to determine the proportion of ED patients who initially are assessed as having nonurgent conditions, but subsequently are hospitalized. DESIGN: Cross-sectional survey during a single 24-hour period of time. SETTING: Fifty-six hospital EDs nationwide. PATIENTS OR OTHER PARTICIPANTS: Consecutive ambulatory patients presenting for care. Patents who arrived by ambulance were excluded. RESULTS: Of 6441 ambulatory patients (79 percent of all ED visits) who were eligible for study, interviews were obtained from 6187 (96 percent). A total of 5323 patients (86 percent) had clinical reasons or preferences for seeking care at an ED, including 2799 (45 percent) who thought they had an emergency or an urgent condition or were too sick to go elsewhere. Nineteen percent (n=1199) reported that they were sent to the ED by a health care professional. Patients with a regular clinician or with insurance cited similar reasons for seeking care at an ED. A total of 3062 patients (50 percent) cited 1 or more nonfinancial barriers to care as an important reason for coming to the ED, and 949 (15 percent) cited financial considerations. A total of 3045 patents (49 percent of ambulatory patients and 37 percent of total ED visits) were assessed at triage as having a nonurgent condition; 166 of them (5.5 percent; 95 percent confidence interval, 4.7 percent-6.3 percent) were admitted to the hospital. CONCLUSIONS: Most ambulatory patients seek care in an ED because of worrisome symptoms or nonfinancial barriers to care. Although many ambulatory patients appear to have nonurgent conditions based on triage classification, a small but disturbing percentage of nonurgent patients are hospitalized.

While cocaine is now used much more frequently than heroin by women of childbearing age, we have found that a significant number of mothers have abused both drugs during their pregnancy. We studied 86 infants who were born to women with a history of cocaine and/or heroin use during pregnancy. The newborns were observed over a 5-day hospital period using a standardized abstinence scoring system and urine drug screening of both mother and infant. Of these, 35 had maternal and/or newborn urine test results that were positive for cocaine only (cocaine group), 14 that were positive for heroin only (heroin group), 17 that were positive for both cocaine and heroin (cocaine/heroin group), and 20 that were negative for both, although the mothers admitted to cocaine use during their pregnancy (cocaine history group). In approximately half of the mother/infant pairs, the results of the urine drug tests were discordant. Microcephaly and growth retardation occurred most frequently in the infants in the cocaine group (17% and 27%, respectively). Microcephaly was also found to be significant in the infants in the cocaine/heroin group. Signs of drug withdrawal occurred in all four drug-exposed groups. Mild withdrawal occurred in 26% of infants in the cocaine group, 21% of the infants in the heroin group, 47% of the infants in the cocaine/heroin group, and in 30% of the infants in the cocaine history group. Withdrawal requiring treatment occurred in 6% of the infants in the cocaine group, 14% of the infants in the heroin group, 35% of infants in the cocaine/heroin group, and 5% of the infants in the cocaine history group. The use of heroin with cocaine has a synergistic effect on the behavior of the newborn.

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.