Patient Care

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each column will focus on how the contributor applies one of the “Key Communication” areas in practice.

View a chart outlining key communication tactics

What I Say and Do

I counsel and deliver the diagnosis or give recommendations through a dialogue, instead of a monologue, using active listening.

Why I Do It

The monologue, or lecture, is among the least effective ways to instill behavior change. Research studies have demonstrated that, after a monologue, only around 20% to 60% of medical information is remembered by the end of a visit. Out of what is remembered, less than 50% is accurate. Furthermore, 47% of Americans have health literacy levels below the intermediate range, defined as the ability to determine when to take a medication with food from reading the label.

Lecturing the patient without first understanding what the patient knows and finds important, and understanding the barriers to plan implementation, runs the risk of decreased comprehension, a lack of understanding, or a lack of personal relevance—all leading to decreased adherence. Doing the opposite, by involving the patient in decision making, inspires change that comes from within in the context of the patient’s own needs. This approach is more enduring, emphasizes self-accountability, and ultimately leads to better outcomes.

How I Do It

I open up a dialogue using the Cleveland Clinic’s ARIA approach as adapted from the REDE model of healthcare communication.1

• First, assess: What does the patient know about diagnosis and treatment? How much and what type of education does the patient desire/need? What are the patient’s treatment preferences and health literacy?
• Second, reflect on what the patient just said. Validate meaning and emotion.
• Third, inform the patient within the context of the patient’s perspectives and preferences. Speak slowly and provide small chunks of information at a time. Use understandable language and visual aids. (This will increase recall by 60%.)
• Finally, assess the patient’s understanding and emotional reaction to information provided.
• Repeat the cycle to introduce other chunks of information.

Dr. Velez is director of faculty development in the Center for Excellence in Healthcare Communication at the Cleveland Clinic.

Reference

1. Windover A, Boissy A, Rice T, Gilligan T, Velez V, Merlino J. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Exp. 2014;1(1):8-13.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each column will focus on how the contributor applies one of the “Key Communication” areas in practice.

View a chart outlining key communication tactics

What I Say and Do

I counsel and deliver the diagnosis or give recommendations through a dialogue, instead of a monologue, using active listening.

Why I Do It

The monologue, or lecture, is among the least effective ways to instill behavior change. Research studies have demonstrated that, after a monologue, only around 20% to 60% of medical information is remembered by the end of a visit. Out of what is remembered, less than 50% is accurate. Furthermore, 47% of Americans have health literacy levels below the intermediate range, defined as the ability to determine when to take a medication with food from reading the label.

Lecturing the patient without first understanding what the patient knows and finds important, and understanding the barriers to plan implementation, runs the risk of decreased comprehension, a lack of understanding, or a lack of personal relevance—all leading to decreased adherence. Doing the opposite, by involving the patient in decision making, inspires change that comes from within in the context of the patient’s own needs. This approach is more enduring, emphasizes self-accountability, and ultimately leads to better outcomes.

How I Do It

I open up a dialogue using the Cleveland Clinic’s ARIA approach as adapted from the REDE model of healthcare communication.1

• First, assess: What does the patient know about diagnosis and treatment? How much and what type of education does the patient desire/need? What are the patient’s treatment preferences and health literacy?
• Second, reflect on what the patient just said. Validate meaning and emotion.
• Third, inform the patient within the context of the patient’s perspectives and preferences. Speak slowly and provide small chunks of information at a time. Use understandable language and visual aids. (This will increase recall by 60%.)
• Finally, assess the patient’s understanding and emotional reaction to information provided.
• Repeat the cycle to introduce other chunks of information.

Dr. Velez is director of faculty development in the Center for Excellence in Healthcare Communication at the Cleveland Clinic.

Reference

1. Windover A, Boissy A, Rice T, Gilligan T, Velez V, Merlino J. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Exp. 2014;1(1):8-13.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each column will focus on how the contributor applies one of the “Key Communication” areas in practice.

View a chart outlining key communication tactics

What I Say and Do

I counsel and deliver the diagnosis or give recommendations through a dialogue, instead of a monologue, using active listening.

Why I Do It

The monologue, or lecture, is among the least effective ways to instill behavior change. Research studies have demonstrated that, after a monologue, only around 20% to 60% of medical information is remembered by the end of a visit. Out of what is remembered, less than 50% is accurate. Furthermore, 47% of Americans have health literacy levels below the intermediate range, defined as the ability to determine when to take a medication with food from reading the label.

Lecturing the patient without first understanding what the patient knows and finds important, and understanding the barriers to plan implementation, runs the risk of decreased comprehension, a lack of understanding, or a lack of personal relevance—all leading to decreased adherence. Doing the opposite, by involving the patient in decision making, inspires change that comes from within in the context of the patient’s own needs. This approach is more enduring, emphasizes self-accountability, and ultimately leads to better outcomes.

How I Do It

I open up a dialogue using the Cleveland Clinic’s ARIA approach as adapted from the REDE model of healthcare communication.1

• First, assess: What does the patient know about diagnosis and treatment? How much and what type of education does the patient desire/need? What are the patient’s treatment preferences and health literacy?
• Second, reflect on what the patient just said. Validate meaning and emotion.
• Third, inform the patient within the context of the patient’s perspectives and preferences. Speak slowly and provide small chunks of information at a time. Use understandable language and visual aids. (This will increase recall by 60%.)
• Finally, assess the patient’s understanding and emotional reaction to information provided.
• Repeat the cycle to introduce other chunks of information.

Dr. Velez is director of faculty development in the Center for Excellence in Healthcare Communication at the Cleveland Clinic.

Reference

1. Windover A, Boissy A, Rice T, Gilligan T, Velez V, Merlino J. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Exp. 2014;1(1):8-13.

Clinical question: What is the harm associated with long-term beta-blocker therapy in patients with uncomplicated hypertension undergoing non-cardiac surgery?

Background: Given the recent concerns over the validity of prior studies, there is uncertainty about which patients benefit most from perioperative beta-blockade. Current guidelines suggest continuing beta-blockers in the perioperative period. More data are needed to delineate which patients maximally benefit from perioperative beta-blockade.

Study design: Association study.

Setting: Danish nationwide cohort of patients.

Synopsis: Study investigators included 55,320 uncomplicated hypertension (no cardiovascular, renal, or liver disease) patients >19 years of age on ≥2 antihypertensive drugs undergoing non-cardiac surgery. In the 14,664 patients who received beta-blockers, the rates of 30-day major adverse cardiovascular events (MACE; cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction) and 30-day all-cause mortality were 1.32% and 1.93%, respectively. However, in the 40,676 patients who did not receive beta-blockers, 30-day MACEs and 30-day all-cause mortality rates were 0.84% and 1.32%, respectively (P<0.001). When looking at the individual MACEs, cardiovascular death was the only statistically significant event with higher incidence (0.9% versus 0.45%, P<0.001).

Combination therapy with beta-blocker and RAS inhibitor, calcium channel blockers, or thiazide was associated with statistically significant higher risks of MACEs and all-cause mortality when compared to the combination of RAS inhibitor plus thiazide. Men >70 years of age or undergoing urgent surgery had the highest risk of harm. This study was not a randomized control trial, so caution must be used when attributing causality to beta-blockers, MACEs, and all-cause mortality.

Bottom line: Antihypertensive regimens containing beta-blockers may increase risk of perioperative MACEs and all-cause mortality in patients with uncomplicated hypertension.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. β-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: What is the harm associated with long-term beta-blocker therapy in patients with uncomplicated hypertension undergoing non-cardiac surgery?

Background: Given the recent concerns over the validity of prior studies, there is uncertainty about which patients benefit most from perioperative beta-blockade. Current guidelines suggest continuing beta-blockers in the perioperative period. More data are needed to delineate which patients maximally benefit from perioperative beta-blockade.

Study design: Association study.

Setting: Danish nationwide cohort of patients.

Synopsis: Study investigators included 55,320 uncomplicated hypertension (no cardiovascular, renal, or liver disease) patients >19 years of age on ≥2 antihypertensive drugs undergoing non-cardiac surgery. In the 14,664 patients who received beta-blockers, the rates of 30-day major adverse cardiovascular events (MACE; cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction) and 30-day all-cause mortality were 1.32% and 1.93%, respectively. However, in the 40,676 patients who did not receive beta-blockers, 30-day MACEs and 30-day all-cause mortality rates were 0.84% and 1.32%, respectively (P<0.001). When looking at the individual MACEs, cardiovascular death was the only statistically significant event with higher incidence (0.9% versus 0.45%, P<0.001).

Combination therapy with beta-blocker and RAS inhibitor, calcium channel blockers, or thiazide was associated with statistically significant higher risks of MACEs and all-cause mortality when compared to the combination of RAS inhibitor plus thiazide. Men >70 years of age or undergoing urgent surgery had the highest risk of harm. This study was not a randomized control trial, so caution must be used when attributing causality to beta-blockers, MACEs, and all-cause mortality.

Bottom line: Antihypertensive regimens containing beta-blockers may increase risk of perioperative MACEs and all-cause mortality in patients with uncomplicated hypertension.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. β-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: What is the harm associated with long-term beta-blocker therapy in patients with uncomplicated hypertension undergoing non-cardiac surgery?

Background: Given the recent concerns over the validity of prior studies, there is uncertainty about which patients benefit most from perioperative beta-blockade. Current guidelines suggest continuing beta-blockers in the perioperative period. More data are needed to delineate which patients maximally benefit from perioperative beta-blockade.

Study design: Association study.

Setting: Danish nationwide cohort of patients.

Synopsis: Study investigators included 55,320 uncomplicated hypertension (no cardiovascular, renal, or liver disease) patients >19 years of age on ≥2 antihypertensive drugs undergoing non-cardiac surgery. In the 14,664 patients who received beta-blockers, the rates of 30-day major adverse cardiovascular events (MACE; cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction) and 30-day all-cause mortality were 1.32% and 1.93%, respectively. However, in the 40,676 patients who did not receive beta-blockers, 30-day MACEs and 30-day all-cause mortality rates were 0.84% and 1.32%, respectively (P<0.001). When looking at the individual MACEs, cardiovascular death was the only statistically significant event with higher incidence (0.9% versus 0.45%, P<0.001).

Combination therapy with beta-blocker and RAS inhibitor, calcium channel blockers, or thiazide was associated with statistically significant higher risks of MACEs and all-cause mortality when compared to the combination of RAS inhibitor plus thiazide. Men >70 years of age or undergoing urgent surgery had the highest risk of harm. This study was not a randomized control trial, so caution must be used when attributing causality to beta-blockers, MACEs, and all-cause mortality.

Bottom line: Antihypertensive regimens containing beta-blockers may increase risk of perioperative MACEs and all-cause mortality in patients with uncomplicated hypertension.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. β-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: What is the prevalence of depression or depressive symptoms in resident physicians?

Background: Depression in resident physicians can lead to poor-quality medical care, increased errors, and long-term morbidity. Prevalence of depression or depressive symptoms has varied in prior studies, and more data are needed to better understand the true prevalence.

Study design: Systematic review and meta-analysis.

Setting: Surgical and nonsurgical residency programs in North America, Asia, Europe, South America, and Africa

Synopsis: Thirty-one cross-sectional studies (9,447 individuals) and 23 longitudinal studies (8,113 individuals) from January 1963 to September 2015 were included in this analysis, with the majority using self-reporting to identify residents with depression or depressive symptoms. Overall prevalence of depression or depressive symptoms was 28.8%, with a range of 20.9% to 43.2%, depending on the screening tool (95% CI, 25.3%–32.5%; P<0.001). There was an increased prevalence in depression or depressive symptoms as the calendar year progressed (slope=0.5% per calendar year increase; 95% CI, 0.03%–0.09%), with no difference in prevalence rates between surgical versus nonsurgical residents, U.S. versus elsewhere, cross-sectional versus longitudinal, or interns versus upper-level residents.

Because studies were heterogeneous with respect to the screening tools and resident population, the prevalence of depression or depressive symptoms cannot be precisely determined.

Bottom line: Prevalence of depression or depressive symptoms ranged from 20.9% to 43.2%, with pooled prevalence of 28.8%, and increased with time.

Citation: Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and met-analysis. JAMA. 2015;314(22):2373-2383.

Clinical question: What is the prevalence of depression or depressive symptoms in resident physicians?

Background: Depression in resident physicians can lead to poor-quality medical care, increased errors, and long-term morbidity. Prevalence of depression or depressive symptoms has varied in prior studies, and more data are needed to better understand the true prevalence.

Study design: Systematic review and meta-analysis.

Setting: Surgical and nonsurgical residency programs in North America, Asia, Europe, South America, and Africa

Synopsis: Thirty-one cross-sectional studies (9,447 individuals) and 23 longitudinal studies (8,113 individuals) from January 1963 to September 2015 were included in this analysis, with the majority using self-reporting to identify residents with depression or depressive symptoms. Overall prevalence of depression or depressive symptoms was 28.8%, with a range of 20.9% to 43.2%, depending on the screening tool (95% CI, 25.3%–32.5%; P<0.001). There was an increased prevalence in depression or depressive symptoms as the calendar year progressed (slope=0.5% per calendar year increase; 95% CI, 0.03%–0.09%), with no difference in prevalence rates between surgical versus nonsurgical residents, U.S. versus elsewhere, cross-sectional versus longitudinal, or interns versus upper-level residents.

Because studies were heterogeneous with respect to the screening tools and resident population, the prevalence of depression or depressive symptoms cannot be precisely determined.

Bottom line: Prevalence of depression or depressive symptoms ranged from 20.9% to 43.2%, with pooled prevalence of 28.8%, and increased with time.

Citation: Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and met-analysis. JAMA. 2015;314(22):2373-2383.

Clinical question: What is the prevalence of depression or depressive symptoms in resident physicians?

Background: Depression in resident physicians can lead to poor-quality medical care, increased errors, and long-term morbidity. Prevalence of depression or depressive symptoms has varied in prior studies, and more data are needed to better understand the true prevalence.

Study design: Systematic review and meta-analysis.

Setting: Surgical and nonsurgical residency programs in North America, Asia, Europe, South America, and Africa

Synopsis: Thirty-one cross-sectional studies (9,447 individuals) and 23 longitudinal studies (8,113 individuals) from January 1963 to September 2015 were included in this analysis, with the majority using self-reporting to identify residents with depression or depressive symptoms. Overall prevalence of depression or depressive symptoms was 28.8%, with a range of 20.9% to 43.2%, depending on the screening tool (95% CI, 25.3%–32.5%; P<0.001). There was an increased prevalence in depression or depressive symptoms as the calendar year progressed (slope=0.5% per calendar year increase; 95% CI, 0.03%–0.09%), with no difference in prevalence rates between surgical versus nonsurgical residents, U.S. versus elsewhere, cross-sectional versus longitudinal, or interns versus upper-level residents.

Because studies were heterogeneous with respect to the screening tools and resident population, the prevalence of depression or depressive symptoms cannot be precisely determined.

Bottom line: Prevalence of depression or depressive symptoms ranged from 20.9% to 43.2%, with pooled prevalence of 28.8%, and increased with time.

Citation: Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and met-analysis. JAMA. 2015;314(22):2373-2383.

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p&lt;0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p&lt;0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p&lt;0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p&lt;0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p&lt;0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p&lt;0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p&lt;0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p&lt;0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p&lt;0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

Clinical question: How frequent is contamination of skin and clothing during personal protective equipment (PPE) removal, and can it be prevented?

Background: PPE reduces transmission of pathogens to healthcare personnel and patients. However, improper removal can lead to contamination of the skin and clothing. Little information exists describing the frequency and sites of contamination after the removal of gloves or gowns.

Study design: Point prevalence study and quasi-experimental intervention.

Setting: Four northeast Ohio hospitals (university, community, county, and VA); intervention performed at VA hospital.

Synopsis: This study began with 435 glove and gown removal simulations performed at four northeast Ohio hospitals. Skin or clothing contamination occurred in 200 (46%) simulations, with similar frequencies across the four hospitals (42.5%–50.3%). Contamination occurred more frequently in the glove removal versus gown removal (52.9% versus 37.8%, P=0.002). Most common causes of contamination were gloves not covering the wrists, removing the gown over the head, donning gloves before the gown, and touching contaminated gloves.

The intervention, performed at the VA hospital, consisted of educational sessions, videos, demonstrations, and practice donning and doffing PPE, which resulted in reduced skin and clothing contamination (60% before versus 18.9% after, P<0.001) that was sustained at one and three months.

Given that the intervention was quasi-experimental and not randomized, it is difficult to attribute

causality to the intervention, and results must be interpreted with caution.

Bottom line: During the removal of gloves and gowns, skin and clothing contamination is frequent, and a simple educational intervention with visual feedback may reduce rates of contamination.

Citation: Tomas ME, Kundrapu S, Thota P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med. 2015;175(12):1904-1910.

Clinical question: How frequent is contamination of skin and clothing during personal protective equipment (PPE) removal, and can it be prevented?

Background: PPE reduces transmission of pathogens to healthcare personnel and patients. However, improper removal can lead to contamination of the skin and clothing. Little information exists describing the frequency and sites of contamination after the removal of gloves or gowns.

Study design: Point prevalence study and quasi-experimental intervention.

Setting: Four northeast Ohio hospitals (university, community, county, and VA); intervention performed at VA hospital.

Synopsis: This study began with 435 glove and gown removal simulations performed at four northeast Ohio hospitals. Skin or clothing contamination occurred in 200 (46%) simulations, with similar frequencies across the four hospitals (42.5%–50.3%). Contamination occurred more frequently in the glove removal versus gown removal (52.9% versus 37.8%, P=0.002). Most common causes of contamination were gloves not covering the wrists, removing the gown over the head, donning gloves before the gown, and touching contaminated gloves.

The intervention, performed at the VA hospital, consisted of educational sessions, videos, demonstrations, and practice donning and doffing PPE, which resulted in reduced skin and clothing contamination (60% before versus 18.9% after, P<0.001) that was sustained at one and three months.

Given that the intervention was quasi-experimental and not randomized, it is difficult to attribute

causality to the intervention, and results must be interpreted with caution.

Bottom line: During the removal of gloves and gowns, skin and clothing contamination is frequent, and a simple educational intervention with visual feedback may reduce rates of contamination.

Citation: Tomas ME, Kundrapu S, Thota P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med. 2015;175(12):1904-1910.

Clinical question: How frequent is contamination of skin and clothing during personal protective equipment (PPE) removal, and can it be prevented?

Background: PPE reduces transmission of pathogens to healthcare personnel and patients. However, improper removal can lead to contamination of the skin and clothing. Little information exists describing the frequency and sites of contamination after the removal of gloves or gowns.

Study design: Point prevalence study and quasi-experimental intervention.

Setting: Four northeast Ohio hospitals (university, community, county, and VA); intervention performed at VA hospital.

Synopsis: This study began with 435 glove and gown removal simulations performed at four northeast Ohio hospitals. Skin or clothing contamination occurred in 200 (46%) simulations, with similar frequencies across the four hospitals (42.5%–50.3%). Contamination occurred more frequently in the glove removal versus gown removal (52.9% versus 37.8%, P=0.002). Most common causes of contamination were gloves not covering the wrists, removing the gown over the head, donning gloves before the gown, and touching contaminated gloves.

The intervention, performed at the VA hospital, consisted of educational sessions, videos, demonstrations, and practice donning and doffing PPE, which resulted in reduced skin and clothing contamination (60% before versus 18.9% after, P<0.001) that was sustained at one and three months.

Given that the intervention was quasi-experimental and not randomized, it is difficult to attribute

causality to the intervention, and results must be interpreted with caution.

Bottom line: During the removal of gloves and gowns, skin and clothing contamination is frequent, and a simple educational intervention with visual feedback may reduce rates of contamination.

Citation: Tomas ME, Kundrapu S, Thota P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med. 2015;175(12):1904-1910.

Clinical question: Can procalcitonin testing be used to determine whether antibiotics should be started and stopped?

Background: Procalcitonin naturally occurs in the body but increases with bacterial infection, with normal levels

Study design: Systematic review.

Setting: ICUs and EDs in Europe, China, and Brazil.

Synopsis: A systematic review of eight RCTs in the ICU showed that, in adults, procalcitonin testing decreased antibiotic duration (weighted mean difference [WMD] -3.2 days; 95% CI, -5.44 to -0.95), decreased hospital length of stay (WMD -3.85 days; 95% CI, -6.78 to -0.92), and trended toward decreased ICU length of stay (WMD -2.03 days; 95% CI, -4.19 to 0.13).

Further review of eight different trials looking at procalcitonin testing in the ED showed that, in adults with suspected bacterial infection, procalcitonin testing reduced proportion of adults receiving antibiotics (relative risk 0.77; 95% CI, 0.68–0.87) and a trend toward reduction in hospital stays. No strong conclusions could be made about the effect on duration of antibiotic therapy. Procalcitonin testing was demonstrated to be cost-effective in the study population, saving £3,268 in adults with sepsis in the ICU.

Most studies were of unclear quality and unclear risk of bias secondary to insufficient reporting; therefore, results must be interpreted with caution.

Bottom line: Procalcitonin testing may be a cost-saving measure for adults with sepsis in the ICU and adults with possible bacterial infections in the ED.

Citation: Westwood M, Raemaekers B, Whiting P, et al. Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2015;19(96):1-236.

Short Take

Adjuvant Flu Vaccine Approved for Prevention of Seasonal Influenza

The FDA approved Fluad, an adjuvanted trivalent vaccine, for the prevention of seasonal influenza in patients >65 years of age based on studies showing comparable safety and immunogenicity to Agriflu, a FDA-approved unadjuvanted trivalent vaccine.

Citation: FDA approves first seasonal influenza vaccine containing an adjuvant [news release]. Washington, DC: FDA; November 24, 2015

Clinical question: Can procalcitonin testing be used to determine whether antibiotics should be started and stopped?

Background: Procalcitonin naturally occurs in the body but increases with bacterial infection, with normal levels

Study design: Systematic review.

Setting: ICUs and EDs in Europe, China, and Brazil.

Synopsis: A systematic review of eight RCTs in the ICU showed that, in adults, procalcitonin testing decreased antibiotic duration (weighted mean difference [WMD] -3.2 days; 95% CI, -5.44 to -0.95), decreased hospital length of stay (WMD -3.85 days; 95% CI, -6.78 to -0.92), and trended toward decreased ICU length of stay (WMD -2.03 days; 95% CI, -4.19 to 0.13).

Further review of eight different trials looking at procalcitonin testing in the ED showed that, in adults with suspected bacterial infection, procalcitonin testing reduced proportion of adults receiving antibiotics (relative risk 0.77; 95% CI, 0.68–0.87) and a trend toward reduction in hospital stays. No strong conclusions could be made about the effect on duration of antibiotic therapy. Procalcitonin testing was demonstrated to be cost-effective in the study population, saving £3,268 in adults with sepsis in the ICU.

Most studies were of unclear quality and unclear risk of bias secondary to insufficient reporting; therefore, results must be interpreted with caution.

Bottom line: Procalcitonin testing may be a cost-saving measure for adults with sepsis in the ICU and adults with possible bacterial infections in the ED.

Citation: Westwood M, Raemaekers B, Whiting P, et al. Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2015;19(96):1-236.

Short Take

Adjuvant Flu Vaccine Approved for Prevention of Seasonal Influenza

The FDA approved Fluad, an adjuvanted trivalent vaccine, for the prevention of seasonal influenza in patients >65 years of age based on studies showing comparable safety and immunogenicity to Agriflu, a FDA-approved unadjuvanted trivalent vaccine.

Citation: FDA approves first seasonal influenza vaccine containing an adjuvant [news release]. Washington, DC: FDA; November 24, 2015

Clinical question: Can procalcitonin testing be used to determine whether antibiotics should be started and stopped?

Background: Procalcitonin naturally occurs in the body but increases with bacterial infection, with normal levels

Study design: Systematic review.

Setting: ICUs and EDs in Europe, China, and Brazil.

Synopsis: A systematic review of eight RCTs in the ICU showed that, in adults, procalcitonin testing decreased antibiotic duration (weighted mean difference [WMD] -3.2 days; 95% CI, -5.44 to -0.95), decreased hospital length of stay (WMD -3.85 days; 95% CI, -6.78 to -0.92), and trended toward decreased ICU length of stay (WMD -2.03 days; 95% CI, -4.19 to 0.13).

Further review of eight different trials looking at procalcitonin testing in the ED showed that, in adults with suspected bacterial infection, procalcitonin testing reduced proportion of adults receiving antibiotics (relative risk 0.77; 95% CI, 0.68–0.87) and a trend toward reduction in hospital stays. No strong conclusions could be made about the effect on duration of antibiotic therapy. Procalcitonin testing was demonstrated to be cost-effective in the study population, saving £3,268 in adults with sepsis in the ICU.

Most studies were of unclear quality and unclear risk of bias secondary to insufficient reporting; therefore, results must be interpreted with caution.

Bottom line: Procalcitonin testing may be a cost-saving measure for adults with sepsis in the ICU and adults with possible bacterial infections in the ED.

Citation: Westwood M, Raemaekers B, Whiting P, et al. Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2015;19(96):1-236.

Short Take

Adjuvant Flu Vaccine Approved for Prevention of Seasonal Influenza

The FDA approved Fluad, an adjuvanted trivalent vaccine, for the prevention of seasonal influenza in patients >65 years of age based on studies showing comparable safety and immunogenicity to Agriflu, a FDA-approved unadjuvanted trivalent vaccine.

Citation: FDA approves first seasonal influenza vaccine containing an adjuvant [news release]. Washington, DC: FDA; November 24, 2015

Clinical question: What is the risk of acute kidney injury after orthopedic surgery, and does it impact mortality?

Background: Current studies show that acute kidney injury is associated with increased long-term mortality, future development of chronic kidney disease, and increased healthcare costs. However, no externally validated models are available to predict patients undergoing non-cardiac surgery at risk of postoperative acute kidney injury.

Study design: Observational, cohort study.

Setting: Teaching and private hospitals in the National Health Service (NHS) in the Tayside region of Scotland.

Synopsis: Investigators enrolled 10,615 adults >18 years of age undergoing orthopedic surgery into two groups: development cohort (6,220 patients) and validation cohort (4,395 patients). Using the development cohort, seven predictors were identified in the risk model: age at operation, male sex, diabetes, lower estimated glomerular filtration rate (GFR), use of ACE inhibitor/ARB, number of prescribing drugs, and American Society of Anesthesiologists (ASA) grade.

The model’s predictive performance for discrimination was good in the development cohort (C statistic 0.74; 95% CI, 0.72–0.76) and validation cohort (C statistic 0.7). Calibration was good in the development cohort but overestimated the risk in the validation cohort. Postoperative acute kidney injury developed in 672 (10.8%) patients in the development cohort and 295 (6.7%) in the validation cohort. Thirty percent (3,166) of the 10,615 patients enrolled in this study died over the median follow-up of 4.58 years. Survival was worse in the patients with acute kidney injury (adjusted hazard ratio 1.53; 95% CI, 1.38–1.70), worse in the short term (90-day adjusted hazard ratio 2.36; 95% CI, 1.94–2.87), and diminished over time.

Bottom line: A predictive model using age, male sex, diabetes, lower GFR, use of ACE inhibitor/ARB, multiple medications, and ASA grades might predict risk of postoperative acute kidney injury in orthopedic patients.

Citation: Bell S, Dekker FW, Vadiveloo T, et al. Risk of postoperative acute kidney injury in patients undergoing orthopaedic surgery—development and validation of a risk score and effect of acute kidney injury on survival: observational cohort study. BMJ 2015; 351:h5639.

Clinical question: What is the risk of acute kidney injury after orthopedic surgery, and does it impact mortality?

Background: Current studies show that acute kidney injury is associated with increased long-term mortality, future development of chronic kidney disease, and increased healthcare costs. However, no externally validated models are available to predict patients undergoing non-cardiac surgery at risk of postoperative acute kidney injury.

Study design: Observational, cohort study.

Setting: Teaching and private hospitals in the National Health Service (NHS) in the Tayside region of Scotland.

Synopsis: Investigators enrolled 10,615 adults >18 years of age undergoing orthopedic surgery into two groups: development cohort (6,220 patients) and validation cohort (4,395 patients). Using the development cohort, seven predictors were identified in the risk model: age at operation, male sex, diabetes, lower estimated glomerular filtration rate (GFR), use of ACE inhibitor/ARB, number of prescribing drugs, and American Society of Anesthesiologists (ASA) grade.

The model’s predictive performance for discrimination was good in the development cohort (C statistic 0.74; 95% CI, 0.72–0.76) and validation cohort (C statistic 0.7). Calibration was good in the development cohort but overestimated the risk in the validation cohort. Postoperative acute kidney injury developed in 672 (10.8%) patients in the development cohort and 295 (6.7%) in the validation cohort. Thirty percent (3,166) of the 10,615 patients enrolled in this study died over the median follow-up of 4.58 years. Survival was worse in the patients with acute kidney injury (adjusted hazard ratio 1.53; 95% CI, 1.38–1.70), worse in the short term (90-day adjusted hazard ratio 2.36; 95% CI, 1.94–2.87), and diminished over time.

Bottom line: A predictive model using age, male sex, diabetes, lower GFR, use of ACE inhibitor/ARB, multiple medications, and ASA grades might predict risk of postoperative acute kidney injury in orthopedic patients.

Citation: Bell S, Dekker FW, Vadiveloo T, et al. Risk of postoperative acute kidney injury in patients undergoing orthopaedic surgery—development and validation of a risk score and effect of acute kidney injury on survival: observational cohort study. BMJ 2015; 351:h5639.

Clinical question: What is the risk of acute kidney injury after orthopedic surgery, and does it impact mortality?

Background: Current studies show that acute kidney injury is associated with increased long-term mortality, future development of chronic kidney disease, and increased healthcare costs. However, no externally validated models are available to predict patients undergoing non-cardiac surgery at risk of postoperative acute kidney injury.

Study design: Observational, cohort study.

Setting: Teaching and private hospitals in the National Health Service (NHS) in the Tayside region of Scotland.

Synopsis: Investigators enrolled 10,615 adults >18 years of age undergoing orthopedic surgery into two groups: development cohort (6,220 patients) and validation cohort (4,395 patients). Using the development cohort, seven predictors were identified in the risk model: age at operation, male sex, diabetes, lower estimated glomerular filtration rate (GFR), use of ACE inhibitor/ARB, number of prescribing drugs, and American Society of Anesthesiologists (ASA) grade.

The model’s predictive performance for discrimination was good in the development cohort (C statistic 0.74; 95% CI, 0.72–0.76) and validation cohort (C statistic 0.7). Calibration was good in the development cohort but overestimated the risk in the validation cohort. Postoperative acute kidney injury developed in 672 (10.8%) patients in the development cohort and 295 (6.7%) in the validation cohort. Thirty percent (3,166) of the 10,615 patients enrolled in this study died over the median follow-up of 4.58 years. Survival was worse in the patients with acute kidney injury (adjusted hazard ratio 1.53; 95% CI, 1.38–1.70), worse in the short term (90-day adjusted hazard ratio 2.36; 95% CI, 1.94–2.87), and diminished over time.

Bottom line: A predictive model using age, male sex, diabetes, lower GFR, use of ACE inhibitor/ARB, multiple medications, and ASA grades might predict risk of postoperative acute kidney injury in orthopedic patients.

Citation: Bell S, Dekker FW, Vadiveloo T, et al. Risk of postoperative acute kidney injury in patients undergoing orthopaedic surgery—development and validation of a risk score and effect of acute kidney injury on survival: observational cohort study. BMJ 2015; 351:h5639.

Clinical question: Does treating asymptomatic bacteriuria (AB) cause harm in women?

Background: In women with recurrent UTIs, AB is often treated, increasing the risk of multi-drug-resistant bacteria. At the same time, little data exist on the relationship between AB treatment and risk of higher antibiotic resistance in women with recurrent UTIs.

Study design: Follow-up observational, analytical, longitudinal study on a previously randomized clinical trial (RCT).

Setting: Sexually transmitted disease (STD) center in Florence, Italy.

Synopsis: Using the patients from the authors’ previous RCT, the study followed 550 women with recurrent UTIs and AB for a mean of 38.8 months in parallel groups: One group had AB treated, and the other group did not. In the group of women treated with antibiotics, the recurrence rate was 69.6% versus 37.7% in the group not treated (P<0.001). In addition, E. coli isolates showed more resistance to amoxicillin/clavulanic acid (P=0.03), trimethoprim/sulfamethazole (P=0.01), and ciprofloxacin (P=0.03) in the group previously treated with antibiotics.

Given the observational design of the study, data must be interpreted with caution in determining a causal relationship. However, prior studies have shown this relationship, and current Infectious Diseases Society of America guidelines support neither screening nor treating AB.

Bottom line: In women with recurrent UTIs, previous treatment of AB is associated with higher rates of antibiotic-resistant bacteria, causing symptomatic UTIs.

Citation: Cai T, Nsei G, Mazzoli S, et al. Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infection. Clin Infect Dis. 2015;61(11):1655-1661.

Short Take

National Healthcare Spending Increased in 2014

Led by expansions under the Affordable Care Act, healthcare spending increased 5.3% from the previous year and now totals $3 trillion, which represents 17.5% of the gross domestic product.

Citation: Martin AB, Hartman M, Benson J, Catlin A. National health spending in 2014: faster growth drive by coverage expansion and prescription drug spending. Health Aff. 2016;35(1):150-160.

Clinical question: Does treating asymptomatic bacteriuria (AB) cause harm in women?

Background: In women with recurrent UTIs, AB is often treated, increasing the risk of multi-drug-resistant bacteria. At the same time, little data exist on the relationship between AB treatment and risk of higher antibiotic resistance in women with recurrent UTIs.

Study design: Follow-up observational, analytical, longitudinal study on a previously randomized clinical trial (RCT).

Setting: Sexually transmitted disease (STD) center in Florence, Italy.

Synopsis: Using the patients from the authors’ previous RCT, the study followed 550 women with recurrent UTIs and AB for a mean of 38.8 months in parallel groups: One group had AB treated, and the other group did not. In the group of women treated with antibiotics, the recurrence rate was 69.6% versus 37.7% in the group not treated (P<0.001). In addition, E. coli isolates showed more resistance to amoxicillin/clavulanic acid (P=0.03), trimethoprim/sulfamethazole (P=0.01), and ciprofloxacin (P=0.03) in the group previously treated with antibiotics.

Given the observational design of the study, data must be interpreted with caution in determining a causal relationship. However, prior studies have shown this relationship, and current Infectious Diseases Society of America guidelines support neither screening nor treating AB.

Bottom line: In women with recurrent UTIs, previous treatment of AB is associated with higher rates of antibiotic-resistant bacteria, causing symptomatic UTIs.

Citation: Cai T, Nsei G, Mazzoli S, et al. Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infection. Clin Infect Dis. 2015;61(11):1655-1661.

Short Take

National Healthcare Spending Increased in 2014

Led by expansions under the Affordable Care Act, healthcare spending increased 5.3% from the previous year and now totals $3 trillion, which represents 17.5% of the gross domestic product.

Citation: Martin AB, Hartman M, Benson J, Catlin A. National health spending in 2014: faster growth drive by coverage expansion and prescription drug spending. Health Aff. 2016;35(1):150-160.

Clinical question: Does treating asymptomatic bacteriuria (AB) cause harm in women?

Background: In women with recurrent UTIs, AB is often treated, increasing the risk of multi-drug-resistant bacteria. At the same time, little data exist on the relationship between AB treatment and risk of higher antibiotic resistance in women with recurrent UTIs.

Study design: Follow-up observational, analytical, longitudinal study on a previously randomized clinical trial (RCT).

Setting: Sexually transmitted disease (STD) center in Florence, Italy.

Synopsis: Using the patients from the authors’ previous RCT, the study followed 550 women with recurrent UTIs and AB for a mean of 38.8 months in parallel groups: One group had AB treated, and the other group did not. In the group of women treated with antibiotics, the recurrence rate was 69.6% versus 37.7% in the group not treated (P<0.001). In addition, E. coli isolates showed more resistance to amoxicillin/clavulanic acid (P=0.03), trimethoprim/sulfamethazole (P=0.01), and ciprofloxacin (P=0.03) in the group previously treated with antibiotics.

Given the observational design of the study, data must be interpreted with caution in determining a causal relationship. However, prior studies have shown this relationship, and current Infectious Diseases Society of America guidelines support neither screening nor treating AB.

Bottom line: In women with recurrent UTIs, previous treatment of AB is associated with higher rates of antibiotic-resistant bacteria, causing symptomatic UTIs.

Citation: Cai T, Nsei G, Mazzoli S, et al. Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infection. Clin Infect Dis. 2015;61(11):1655-1661.

Short Take

National Healthcare Spending Increased in 2014

Led by expansions under the Affordable Care Act, healthcare spending increased 5.3% from the previous year and now totals $3 trillion, which represents 17.5% of the gross domestic product.

Citation: Martin AB, Hartman M, Benson J, Catlin A. National health spending in 2014: faster growth drive by coverage expansion and prescription drug spending. Health Aff. 2016;35(1):150-160.

Alyssa Stephany, MD, then assistant professor at Duke and now section chief of pediatric hospital medicine at Children’s Hospital of Wisconsin, talks about the evolution in training stemming from her experience in the HM16 RIV competition. This year, she oversaw a study for which resident

Jennifer Ladd, MD, won an award for pediatric clinical vignette.

Alyssa Stephany, MD, then assistant professor at Duke and now section chief of pediatric hospital medicine at Children’s Hospital of Wisconsin, talks about the evolution in training stemming from her experience in the HM16 RIV competition. This year, she oversaw a study for which resident

Jennifer Ladd, MD, won an award for pediatric clinical vignette.

Alyssa Stephany, MD, then assistant professor at Duke and now section chief of pediatric hospital medicine at Children’s Hospital of Wisconsin, talks about the evolution in training stemming from her experience in the HM16 RIV competition. This year, she oversaw a study for which resident

Jennifer Ladd, MD, won an award for pediatric clinical vignette.