Saturday, July 16, 2016

NEJM report on ACOs

Using Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared changes in spending and in performance on quality measures from before the start of ACO contracts to after the start of the contracts between beneficiaries served by the 220 ACOs entering the MSSP in mid-2012 (2012 ACO cohort) or January 2013 (2013 ACO cohort) and those served by non-ACO providers (control group), with adjustment for geographic area and beneficiary characteristics...


Adjusted Medicare spending and spending trends were similar in the ACO cohorts and the control group during the precontract period. In 2013, the differential change (i.e., the between-group difference in the change from the precontract period) in total adjusted annual spending was −$144 per beneficiary in the 2012 ACO cohort as compared with the control group (P=0.02), consistent with a 1.4% savings, but only −$3 per beneficiary in the 2013 ACO cohort as compared with the control group (P=0.96). Estimated savings were consistently greater in independent primary care groups than in hospital-integrated groups among 2012 and 2013 MSSP entrants (P=0.005 for interaction). MSSP contracts were associated with improved performance on some quality measures and unchanged performance on others.


The first full year of MSSP contracts was associated with early reductions in Medicare spending among 2012 entrants but not among 2013 entrants. Savings were greater in independent primary care groups than in hospital-integrated groups.

So as far as cost savings go these results were modest and somewhat mixed. I have to wonder if the effects of ACOs on costs will mirror what happened in the mid 90s with the wave of managed care, when there was an initial slash in costs but the “success” was short lived, as the reductions were not sustainable. I put very little stock in the statement that there was partial improvement in quality, since quality really means the weak and unproven surrogate of performance.

Wednesday, July 13, 2016

Higher prevalence of pancreatic cancer in patients newly diagnosed with type 2 diabetes

This is an association that has long been suspected. Additional evidence for the association was found in this study.

Tuesday, July 12, 2016

The effect of high flow nasal oxygen post-extubation, in patients at low risk

Importance Studies of mechanically ventilated critically ill patients that combine populations that are at high and low risk for reintubation suggest that conditioned high-flow nasal cannula oxygen therapy after extubation improves oxygenation compared with conventional oxygen therapy. However, conclusive data about reintubation are lacking.

Objective To determine whether high-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy for preventing reintubation in mechanically ventilated patients at low risk for reintubation.

Design, Setting, and Participants Multicenter randomized clinical trial conducted between September 2012 and October 2014 in 7 intensive care units (ICUs) in Spain. Participants were 527 adult critical patients at low risk for reintubation who fulfilled criteria for planned extubation. Low risk for reintubation was defined as younger than 65 years; Acute Physiology and Chronic Health Evaluation II score less than 12 on day of extubation; body mass index less than 30; adequate secretions management; simple weaning; 0 or 1 comorbidity; and absence of heart failure, moderate-to-severe chronic obstructive pulmonary disease, airway patency problems, and prolonged mechanical ventilation.

Interventions Patients were randomized to undergo either high-flow or conventional oxygen therapy for 24 hours after extubation.

Main Outcomes and Measures The primary outcome was reintubation within 72 hours, compared with the Cochran-Mantel-Haenszel χ2 test. Secondary outcomes included postextubation respiratory failure, respiratory infection, sepsis and multiorgan failure, ICU and hospital length of stay and mortality, adverse events, and time to reintubation.

Results Of 527 patients (mean age, 51 years [range, 18-64]; 62% men), 264 received high-flow therapy and 263 conventional oxygen therapy. Reintubation within 72 hours was less common in the high-flow group (13 patients [4.9%] vs 32 [12.2%] in the conventional group; absolute difference, 7.2% [95% CI, 2.5% to 12.2%]; P = .004). Postextubation respiratory failure was less common in the high-flow group (22/264 patients [8.3%] vs 38/263 [14.4%] in the conventional group; absolute difference, 6.1% [95% CI, 0.7% to 11.6%]; P = .03). Time to reintubation was not significantly different between groups (19 hours [interquartile range, 12-28] in the high-flow group vs 15 hours [interquartile range, 9-31] in the conventional group; absolute difference, −4 [95% CI, −54 to 46]; P = .66]. No adverse effects were reported.

Conclusions and Relevance Among extubated patients at low risk for reintubation, the use of high-flow nasal cannula oxygen compared with conventional oxygen therapy reduced the risk of reintubation within 72 hours.

Monday, July 11, 2016

Hepatitis B and C associated glomerular diseases

From a recent review:

The most common histopathologic presentation of HBV-GN is HBV-associated membranous nephropathy, which usually manifests clinically with varying grades of proteinuria and microscopic hematuria. The pathogenesis is likely to be immune complex mediated; however, other host and viral factors have been implicated. The treatment of HBV-GN revolves around antiviral therapy. Various histologic types of glomerular diseases are reported in association with HCV infection, the most frequent being Type 1 membranoproliferative glomerulonephritis, usually in the context of Type 2 mixed cryoglobulinemia. The pathogenesis of HCV-GN can be attributed to glomerular deposition of cryoglobulins or noncryoglobulin-immune complexes. Cryoglobulins typically comprised immunoglobulin Mκ with rheumatoid factor activity. Clinically, patients may present with proteinuria, microscopic hematuria, hypertension, and acute nephritic and/or nephrotic syndrome. The treatment of HCV-GN, especially cryoglobulinemic membranoproliferative glomerulonephritis, encompasses various options including contemporary antiviral therapy with or without conventional and novel immunomodulatory agents.

Mentioned in the body of the paper are several other glomerular diseases that have been associated with hep B as well as polyarteritis nodosa which, though not a cause of glomerulonephritis, can cause renal damage as part of the vasculitis.

Sunday, July 10, 2016

How to work up hematuria

This topic was recently reviewed in Advances in Chronic Kidney Disease. From the body of the paper:

On finding a urine dipstick positive for blood, the test should be repeated after several days, to account for any transient causes of MH, such as physical activity, sexual intercourse, or menstruation. If the dipstick remains positive, urine microscopy should be performed to identify RBCs and to define their morphology (dysmorphic or isomorphic)..For our purposes, we define MH as 3 or more RBC/hpf. If no RBCs are visualized, patients should be evaluated for alternative causes of a positive dipstick, such as myoglobinuria. We agree with the CUA guidelines 2 and Huussen and colleagues, 35 who suggest that urologic imaging and cystoscopy may not be required if dysmorphic cells or RBC casts are seen, suggesting a glomerular etiology. Such findings should, however, prompt assessment of kidney function and urinary protein excretion. If the patient has a reduced GFR or proteinuria, referral to nephrology is warranted and a kidney biopsy should be considered. For those individuals with isolated glomerular MH, a clinician should assess these patients annually for kidney function changes and/or the development of albuminuria or proteinuria. If isomorphic RBCs are seen on urine microscopy, the clinician should confirm with the patient whether possible benign causes of MH such as recent physical activity or trauma, sexual activity, menstrual bleeding, viral symptoms, or urethral instrumentation may account for these findings. If a benign cause is present, a repeat urinalysis should be done in several weeks to ensure resolution. If the earlier mentioned causes are not identified, imaging of the GU tract is indicated. Although CTU has demonstrated the best testing characteristics, we emphasize the importance of limiting cumulative doses of radiation exposure, especially in younger individuals..alternative imaging modalities should be considered, including US or MR...

If no parenchymal lesion is detected on imaging, the clinician should assess the patient's GU cancer risk factor profile. If risk factors are present, they should be promptly referred to urology for cystoscopy. If a patient has no such risk factors, age should be considered before undergoing cystoscopic evaluation. We consider the evidence presented in the 2012 AUA guidelines inadequate to support cystoscopy for anyone with asymptomatic MH younger than 40 years. Patients with asymptomatic MH aged 50 years or older have sufficient cancer risk to warrant cystoscopy, regardless of risk factor profile. 6 For patients aged 40 to 49 years, the data are unclear; if no risk factors are present, clinical judgment for cystoscopy referral is advised.

Saturday, July 09, 2016

Progress in the understanding and treatment of hairy cell leukemia

From a recent review:

Initially a uniformly fatal disease, new therapies in rapid succession transformed HCL into a chronic disease with a normal life expectancy in many cases. More recently, the identification of BRAFV600E mutations in the majority of patients with classic HCL have enabled targeted therapies as a therapeutic option. Additional discoveries into the biology of the disease have identified new subtypes of HCL. Modern approaches to the evaluation and treatment of HCL include detailed molecular analysis which informs therapeutic options, which may consist of traditional therapies such as purine nucleoside analogs, or targeted therapies with antibodies, BTK inhibitors, or BRAF inhibitors, or combination therapy.

Sunday, July 03, 2016

Genetics of eosiniphilic esophagitis

This is reviewed in a recent paper. Though not inherited in a simple Mendelian fashion it is a disease of genetic predisposition. This results in considerable overlap with atopic conditions. Some key points:

EoE is a complex genetic disease. Five susceptibility loci have been identified to date.

Three of the EoE predisposition loci are shared across other atopic phenotypes; the remaining two appear to be specific to EoE

The effect sizes of the shared loci are more significant in EoE which may facilitate the characterization of the loci and development of novel therapy.

Saturday, July 02, 2016

Fresh fruit consumption and cardiovascular disease

From a recent study:
In Western populations, a higher level of fruit consumption has been associated with a lower risk of cardiovascular disease, but little is known about such associations in China, where the consumption level is low and rates of stroke are high.

Between 2004 and 2008, we recruited 512,891 adults, 30 to 79 years of age, from 10 diverse localities in China. During 3.2 million person-years of follow-up, 5173 deaths from cardiovascular disease, 2551 incident major coronary events (fatal or nonfatal), 14,579 ischemic strokes, and 3523 intracerebral hemorrhages were recorded among the 451,665 participants who did not have a history of cardiovascular disease or antihypertensive treatments at baseline. Cox regression yielded adjusted hazard ratios relating fresh fruit consumption to disease rates.


Overall, 18.0% of participants reported consuming fresh fruit daily. As compared with participants who never or rarely consumed fresh fruit (the “nonconsumption” category), those who ate fresh fruit daily had lower systolic blood pressure (by 4.0 mm Hg) and blood glucose levels (by 0.5 mmol per liter [9.0 mg per deciliter]) (P<0 .001="" 0.54="" 0.56="" 0.58="" 0.60="" 0.64="" 0.66="" 0.67="" 0.72="" 0.74="" 0.75="" 0.79="" 10="" a="" across="" adjusted="" amount="" and="" associations="" baseline="" between="" both="" by="" cardiovascular="" characteristics.="" ci="" comparisons="" confidence="" consumed.="" consumption="" coronary="" daily="" death="" defined="" dose="" each="" events="" for="" fresh="" fruit="" hazard="" hemorrhagic="" in="" incidence="" incident="" interval="" ischemic="" log-linear="" major="" nonconsumption="" of="" outcome="" p="" participants="" ratios="" regions="" relationship="" respectively="" response="" similar="" stroke.="" stroke="" strong="" study="" subgroups="" the="" there="" these="" to="" trend="" versus="" was="" were="">

Among Chinese adults, a higher level of fruit consumption was associated with lower blood pressure and blood glucose levels and, largely independent of these and other dietary and nondietary factors, with significantly lower risks of major cardiovascular diseases.

This was a study from China. Note that fresh fruit consumption is a component of the Mediterranean diet.

Friday, July 01, 2016

Hyponatremia in cirrhosis

This was the subject of a recent review in Advances in Chronic Kidney Disease. From the article:

Cirrhosis is characterized by systemic and splanchnic vasodilation that leads to excessive nonosmotic secretion of vasopressin (antidiuretic hormone). Hyponatremia is a common electrolyte abnormality in advanced liver disease that results from the impaired ability of the kidney to excrete solute-free water that leads to “dilutional” hyponatremia—water retention disproportionate to the retention of sodium.

The excessive vasodilation is mediated by nitric oxide (NO). NO synthesis in endothelial cells of cirrhotic patients is induced by high levels of circulating endotoxins translocated from the gut having bypassed the portal circulation.

Besides non osmotic vasopressin release the paper also mentions impaired water delivery to the thick ascending limb of the Loop of Henle as a contributing mechanism.

More from the paper:

Hyponatremia in liver diseases carries the prognostic burden, correlates with the severity of cirrhosis, and, in recent studies, has also been implicated in the pathogenesis of hepatic encephalopathy.

Hyponatremia's contribution to hepatic encephalopathy is complex. Not only do the manifestations of hyponatremic encephalopathy overlap considerably with those of hepatic encephalopathy but hyponatremia is contributory to the pathogenesis of hepatic encephalopathy itself by multiple mechanisms. One of these involves the exhaustion of certain astrocyte functions as a result of the extrusion of ions and organic molecules as an adaptive response to hyponatremia.

As a prognostic indicator, hyponatremia is associated with hepatorenal syndrome and spontaneous bacterial peritonitis.

Although hyponatremia is associated with adverse outcomes in cirrhosis, at what level one should attempt to raise the sodium and by what means are unclear. The article recommends against the use of demeclocycline to treat hyponatremia in cirrhosis despite its popularity in the treatment of hyponatremia of a variety of causes.