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Failures in Infectious Agent Transmission Precautions
In this qualitative study, Krein and colleagues examined types of precaution practice violations and errors in reducing transmission of infectious agents by hospital personnel in clinical units. Trained observers recorded notes while personnel provided care for patients in precautions for a pathogen transmitted through contact or respiratory droplet. Specific occurrences involving potential personnel self-contamination were identified through a directed content analysis. Of 325 room observations, 283 failures were observed, including 102 violations (deviations from safe operating practices or procedures), 144 process or procedural mistakes (failures of intention), and 37 slips (failures of execution), all of which could result in self-contamination. Horwitz provides the Invited Commentary.
Amputation Rates in Patients With End-stage Renal Disease
For this retrospective study of 3 700 902 records obtained from a US national registry, Franz and colleagues assessed rates of lower extremity amputation among patients with end-stage renal disease who received dialysis to analyze whether those rates differed by age, sex, diabetes, or geographic region, and to determine 1-year mortality rates after lower extremity amputation. Data were analyzed in cross-sectional cohorts for each calendar year from 2000 through 2014. Results demonstrated that for reach annual cohort, patients younger than 65 years had higher adjusted amputation rates than older patients, men had consistently higher adjusted amputation rates than women, patients with diabetes had amputation rates more than 5 times as high as patients without diabetes, and adjusted 1-year mortality rates decreased.
Hospital-at-Home vs Traditional Care
Federman and colleagues compared the patient outcomes and ratings of care between patients who received hospital-at-home care bundled with a 30-day postacute transitional care period vs traditional inpatient care in this case-control study. The primary outcomes were duration of the acute care period and the postacute outcomes of 30-day all-cause hospital readmissions or stand-alone emergency department visits, transfer to a skilled nursing facility, and referral to a certified home health care agency. Results showed that patients receiving hospital-at-home care had shorter length of stay, lower rates of readmissions, and were more likely to rate their hospital care highly. Liao and colleagues provide the Invited Commentary.
Author Audio Interview
Medicaid Payment Increase and Participation Changes
In this longitudinal analysis, Mulcahy and colleagues evaluated the Patient Protection and Affordable Care Act Medicaid primary care payment increase policy and assessed whether it was associated with changes in Medicaid participation rates or Medicaid service volume among primary care physicians (PCPs). Using the observations of 20 723 PCPs in each month from January 1, 2012, to December 31, 2015, results demonstrated the payment increase had no association with PCP participation in Medicaid or Medicaid service volume, although the limited duration and design of the payment increase may have dulled its effectiveness. Goroll provides the Invited Commentary.
Effect of Tamsulosin on Passing Ureteral Stones
Meltzer and colleagues conducted a double-blind, placebo-controlled clinical trial to determine if tamsulosin promoted the passage of urinary stones less than 9 mm in diameter within 28 days among patients in the emergency department. Participants were randomized to treatment with either tamsulosin, 0.4 mg, or matching placebo daily with the primary outcome being stone passage based on visualization or capture by the study participant by day 28. Of the 497 patients evaluated for the primary outcome, stone passage rates were 50% in the tamsulosin group and 47% in the placebo group, a nonsignificant difference. Dahm and Hollingsworth provide the Invited Commentary.
Complications Associated With Urethral Catheters
For this multicenter cohort study, Saint and colleagues examined infectious and noninfectious complications reported by 2076 patients up to a month after receiving an indwelling urethral catheter. A majority of patients had short-term catheters placed for surgical procedures, and during the 30 days after urethral catheter insertion, 1184 patients reported at least 1 complication due to the indwelling urethral catheter. Restrictions in activities of daily living or social activity were also commonly reported by patients who had catheters still in place. Results demonstrated that urethral catheter–associated noninfectious complications should be a focus of surveillance and prevention efforts.
Mortality and Genetic Variation in Caffeine Metabolism
Loftfield and colleagues assessed the association between coffee intake and mortality according to genetic caffeine metabolism scores in this population-based study of UK Biobank data for 498 134 participants. Over 10 years of follow-up, 14 225 deaths occurred; however, coffee drinking was inversely associated with all-cause mortality, including among those drinking 8 or more cups per day and those with genetic polymorphisms indicating slower or faster caffeine metabolism. Results showed the importance of noncaffeine constituents in the coffee-mortality association and provided further reassurance that coffee drinking can be a part of a healthy diet.
Clinical Review & Education
The Carbohydrate-Insulin Model of Obesity
In this article, Ludwig and Ebbeling discussed the association of a high-carbohydrate diet with postprandial hyperinsulinemia, deposition of calories in fat cells instead of oxidation in lean tissues, and predisposition to weight gain. According to the carbohydrate-insulin model of obesity, recent increases in the consumption of processed, high–glycemic-load carbohydrates produce hormonal changes that promote calorie deposition in adipose tissue, exacerbate hunger, and lower energy expenditure. Basic and genetic research provides mechanistic evidence in support of the carbohydrate-insulin model, but further high-quality research will be needed to resolve the debate. Hall and colleagues provide the Invited Commentary.
Continuing Medical Education
Highlights. JAMA Intern Med. 2018;178(8):1009–1110. doi:10.1001/jamainternmed.2017.5224
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