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Strategies for Managing Hepatitis and HE

Liver disease often results from hepatitis that manifests as either an acute event or as a chronic condition, the latter of which can culminate in organ failure, need for transplant, and even death. Hepatitis C virus (HCV) is the most common form of hepatitis, but only one in four patients suffering from it gets diagnosed. The CDC recently recommended that anyone born between 1945 and 1965 receive HCV antibody testing. As many as 1 million new cases of chronic HCV may be uncovered with this dictum. Nonalcoholic fatty liver disease (NAFLD) is another important cause of hepatitis and is the most common cause of elevated liver function tests. It’s expected to become the most common indication for liver transplantation by 2020. Based on current trends in NAFLD, there is great cause for concern on how best to manage these patients. Importantly, cirrhosis is a stage of NAFLD that has been associated with hepatic encephalopathy (HE), a condition associated with cognitive impairment that significantly reduces quality of life (QOL). Symptoms of HE range from subtly altered mental status to deep coma. The cyclical nature of the illness can be difficult to break and doesn’t resolve completely until a transplant is received or the patient dies. The direct and indirect costs of managing HE are rising, and admissions for HE have increased significantly over the past 8 years. Additionally, patients suffering from HE tend to relapse, which can further exacerbate problems. Hepatitis Treatments Becoming More Effective Neomycin, lactulose, and rifaximin are the only FDA-approved treatments for HE, but the therapeutic paradigm is ever-changing. Historically, treatment for overt HE has begun when...
Identifying Post-Op Complications for Readmission in General Surgery

Identifying Post-Op Complications for Readmission in General Surgery

In June 2009, CMS began publishing 30-day readmission data for select medical diseases, resulting in hospital readmissions becoming an important metric for measuring the quality of patient care. The changing regulations issued by CMS means that hospital reimbursements can be reduced based on an adjustment factor determined by a hospital’s expected and observed 30-day readmission rates. These changes have also raised the bar for decreasing unnecessary surgical readmissions. In addition to the financial implications, unplanned hospital readmissions further limit hospital resources. For each patient readmitted, there is an opportunity lost to treat another patient who needs care (see also, Strategies for Reducing Hospital Readmissions). “Reducing the number of 30-day readmissions after surgery is important for institutions as well as patients,” says John F. Sweeney, MD, FACS. “Developing a better understanding of the predictors of readmission for general surgery patients will allow hospitals to develop programs to decrease readmission rates. Surgical patients are different from medical patients because surgery, in and of itself, places them at risk for readmission, above and beyond their medical problems. There is an opportunity to intervene preoperatively to decrease the risk of readmission postoperatively.” Important New Data on Hospital Readmission In the Journal of the American College of Surgeons, Dr. Sweeney and colleagues had a study published that analyzed patient records of 1,442 general surgery patients operated on between 2009 and 2011. Of them, 163 patients (11.3%) were readmitted to the hospital within 30 days of discharge. There is a paucity of information focusing on readmission rates among surgical patients, says Dr. Sweeney. “Although factors associated with 30-day readmission after general surgery procedures are multifactorial,...

Vaccinating Against Hepatitis B in Adults With Diabetes

Since 1996, 29 outbreaks of hepatitis B virus (HBV) infection in long-term care facilities have been reported to the CDC, 25 of which involved adults with diabetes who were receiving assisted blood glucose monitoring. As a result of these reports, the Hepatitis Vaccines Work Group of the Advisory Committee on Immunization Practices (ACIP) created recommendations for hepatitis B vaccination for adults with diabetes that were published in Morbidity and Mortality Weekly Report. Significant Findings & Recommendations According to our investigation, people aged 23 to 59 who had diabetes had 2.1 times the risk of developing acute HBV when compared with those without diabetes. For those aged 60 or older, patients with diabetes were 1.5 times more likely to acquire HBV than those without the disease. The annual incidence of reported acute HBV infection among adults with diabetes is 1.8 per 100,000. It’s believed that an additional 10.5 new cases of HBV infection occur for each reported confirmed case. Data from 2009-2010 Emerging Infections Program sites indicated that the case-fatality rate among HBV-infected people with diagnosed diabetes was 5%, compared with 2% for people without diabetes. On the basis of available information (including information about HBV risk, morbidity and mortality, and cost-effectiveness), the ACIP recommended the following: 1) Unvaccinated adults with diabetes aged 19 to 59 should receive the hepatitis B vaccine. 2) At the discretion of clinicians, the hepatitis B vaccine may be administered to unvaccinated adults with diabetes aged 60 and older. The ACIP recommendation for adults aged 60 and older is not as strong as the recommendation for adults aged 19 to 59 because the estimated cost...

New Guidelines for Assessing Adiposity

The rate of obesity in the United States has reached the epidemic level despite efforts by healthcare providers and patients to improve health-related behaviors and increased efforts to better understand its pathophysiology. “Assessment for excess adiposity is of critical importance,” says Marc-Andre Cornier, MD. To address the issue of assessing adiposity, the American Heart Association (AHA) released a scientific statement to help clinicians. The statement, which was published in the November 1, 2011 issue of Circulation, provides practical guidance for clinical researchers who seek to identify precise measurements for their patients. It also provides recommendations for clinicians who care for patients whose excess weight is a clinical problem. “Before clinicians can recommend treatment options or talk to patients about obesity prevention, they need to know whether a patient is obese,” says Dr. Cornier, who was the lead author of the AHA scientific statement. He adds that there are also new Medicare guidelines for covering obesity treatment that require clinicians to identify whether or not patients are obese. Medicare will cover provider visits for weight loss counseling in patients who screen “positive” for obesity. Reviewing the Methodologies for Assessing Adiposity Healthcare providers and systems are not regularly assessing for excess adiposity with even the simplest, least costly methods, says Dr. Cornier. “Most methods for assessing excess adiposity are not ready for routine clinical use,” he says. “Measuring BMI and waist circumference is currently best to assess adiposity. These are strategies all clinicians should be practicing on a regular basis for patients. Other newer, complex, and more expensive tools are currently available, but physicians need to do a better job utilizing...
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