Olive View-UCLA Medical Center

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality globally. Low-density lipoprotein cholesterol is a causal risk factor for atherosclerotic cardiovascular disease, with multiple classes of cholesterol-lowering therapies effective at reducing atherosclerotic cardiovascular disease risk. Despite robust efficacy data from randomized trials, real-world implementation of guideline-recommended lipid-lowering therapies is suboptimal. Barriers to the implementation of guideline lipid-lowering therapy recommendations exist at the healthcare systems level, the medical therapy level, and the patient level. A combination of strategies, including the incorporation of quality improvement and cost-effectiveness analysis among payers, pharmacist-based educational initiatives, digital health tools directed towards patients, the simplification of drug regimens via polypill, and emerging novel therapies, including PCSK9 gene silencing and editing technologies, may bridge these implementation gaps. This review highlights challenges and solutions to alleviating barriers to optimal implementation of guideline-recommended lipid-lowering therapies.

The incidence and likelihood of kidney function recovery in liver transplant recipients with acute kidney injury (AKI) due to hepatorenal syndrome (HRS) or acute tubular necrosis (ATN) requiring maintenance dialysis remain undefined. Nonetheless, it has been suggested that dependence on dialysis for more than 6 months diminishes the likelihood of renal function recovery. We report a liver transplant recipient with pre-transplantation AKI attributed to HRS with or without ATN who recovered kidney function after more than 10 months on dialysis.

Purpose: To systematically summarize the 100 most-mentioned and most-cited articles from the past decade to analyze research trends in diabetic retinopathy (DR) and the implications on patient education. Methods: The Altmetric Explorer and Web of Science databases were searched for articles on DR published from January 1, 2014, to December 31, 2023. The 100 most-mentioned and most-cited articles were screened from each database, and the publication year, journal, first author's sex, country of origin, total citations, Altmetric Attention score, research topic, and research type were recorded. Article metrics between the 100 most-mentioned and most-cited articles were compared. Results: The 100 most-mentioned articles had a median Altmetric Attention score of 161 and a median citation count of 49. The 100 most-cited articles had a median Altmetric Attention score of 35.5 and a median citation count of 312. JAMA Ophthalmology and Ophthalmology published the highest proportion of most-mentioned and most-cited articles. A strong positive correlation was found between the Altmetric Attention score and citation count for both the most-mentioned (r = 0.420, P < .001) and most-cited articles (r = 0.599, P < .001). The most common research subtopics of the most-mentioned and most-cited articles were epidemiology (42%) and screening (40%). Thirty articles were featured on both lists. Conclusions: The altmetric and bibliometric patterns seen in this study provide insight into the current and future trends in DR research and can be used to inform education outreach initiatives and improve patient outcomes.

Importance:Hospital capacity constraints and rising healthcare costs necessitate innovative models for delivering acute care. While various hospital-substitution models exist, challenges in scalability and long-term viability persist.Objective:To evaluate the feasibility and safety of a novel, high-acuity Next Day Clinic (NDC) as an alternative to hospitalization for select acutely ill emergency department (ED) patients.Design, Setting, and Participants:Retrospective matched cohort study of patients referred to the NDC between July 1, 2023-July 31, 2024, matched to patients seen in the ED during the year prior to NDC launch, within a large academic safety-net hospital.Intervention:High-acuity outpatient therapy for one or more consecutive days in the NDC, consisting of daily IV antibiotics or diuretics, STAT labs, and rapid turnaround imaging and cardiodiagnostics.Main Outcomes and Measures:Days alive and out of hospital (DAOH) in the 30 days following the index ED visit. Secondary outcomes were the number of hospital bed-days avoided, as well as 30-day ED revisits, hospital readmissions, and mortality.Results:The NDC had 1009 encounters (mean age, 54.4 years [SD 14.6]; 448 female [44%]) during the study period, 420 (42%) of which were referred from the ED. Of these, 298 (71%) matched to 4666 ED visits (mean age, 53.3 years [SD 15.2]; 2019 female [43%]) in the year prior to NDC launch on age, sex, the first set of laboratory and vital sign data obtained in the ED (i.e., presenting illness severity), and an exact match on primary diagnosis group. Unadjusted mean DAOH in the NDC cohort was 29.5 days (SD 2.3) compared to 24.9 days (SD 5.5) in the control cohort. Adjusting for the same features in the matching algorithm showed NDC treatment was associated with an average of 3.85 (SD 0.20) more DAOH compared to hospitalization (p<0.001), translating to 358–1294 hospital bed-days saved over the study period. NDC patients had significantly higher rates of 30-day ED revisits per 100 encounters (20.5 versus 13.0, p<0.001), but significantly lower rates of 30-day hospital readmissions per 100 encounters (5.7 versus 11.0, p<0.001) and morality (0% versus 0.9%, p<0.001).Conclusions and Relevance:The NDC is a feasible and safe alternative to hospitalization, and promising strategy for managing ED and hospital capacity and reducing healthcare expenditures.

Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) worldwide, disproportionately affecting underserved and safety-net populations. Los Angeles County Department of Health Services (LAC-DHS) Kidney Health Workgroup has developed pragmatic population health frameworks and Expected Practices for DKD co-management with primary-care providers: pragmatic definitions of low kidney function (LKF, <50% of normal) and very low kidney function (VLKF, <25%), and proteinuria severity classification as early (>150 mg/g), heavy (>1 g/g), and massive (>7 g/g) to guide referral urgency; biopsy-agnostic diagnosis of DKD when four out of five criteria are met, including diabetes history or A1c more than 6%, LKF, proteinuria, diabetic microangiopathy, and larger kidney length (>12 cm) or faster CKD progression (>25 ml/min/year); Kidney Disease Integrated Therapy (KDIT) combining four medication categories (RAAS blockade, SGLT2 inhibitors, GLP-1 agonists, nonsteroidal mineralocorticoid antagonist) and renal nutrition and lifestyle medicine (PLADO/PLAFOND diets), adequate hydration, and exercise; and eConsults to support timely detection, dialysis vascular access placement, shared decision-making, and ESRD care coordination. The DKD management model demonstrates that resource-limited systems can deliver innovative, high-quality kidney care and provide a scalable framework for equity-focused and pragmatic kidney care in municipal health systems.

Gastrointestinal tuberculosis (GI TB) is an uncommon form of extrapulmonary TB (EPTB). While it is more prevalent in endemic regions, its incidence is rising in developed countries due to factors such as immigration, HIV infection, and immunosuppressive therapy. We present a case of a 34-year-old woman with abdominal pain, nausea, and unintentional weight loss who was found to have imaging evidence of terminal ileal and colonic wall thickening, peritoneal thickening, and ascites, and was ultimately diagnosed with gastrointestinal TB after an endoscopic biopsy demonstrated noncaseating granulomatous ileitis, a cecal ulcer, and a positive GeneXpert Mycobacterium tuberculosis polymerase chain reaction (MTB-PCR) result in sputum. This report highlights an unusual presentation characterized by a nonproductive cough and the absence of typical risk factors or manifestations of pulmonary TB. It underscores the importance of considering TB in the broad differential diagnosis for individuals with nonspecific symptoms, as it may mimic inflammatory bowel disease. The patient demonstrated a favorable response to anti-TB treatment, highlighting the significance of early detection and appropriate management of this uncommon disease. We believe this report contributes to the growing body of literature on extrapulmonary manifestations of TB.

Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a life-threatening condition with an estimated mortality of 5-10%. Multiple therapeutic regimens are routinely used, but literature comparing their effectiveness and safety remains limited. Objective: To evaluate the effectiveness of commonly used treatments for DRESS, focusing on mortality, duration of treatment, and adverse effects. Methods: We conducted a PubMed literature review for articles published between 2005 and 2022, including peer-reviewed publications with at least two DRESS patients treated with supportive care, systemic corticosteroids (SCS), intravenous immunoglobulin (IVIG), and/or cyclosporine. We excluded articles that did not clearly delineate the number of patients that received each treatment type and/or respective outcomes. We extracted and analyzed data including patient demographics, implicated drugs, treatment regimens, and outcomes. Results: We included 19 studies encompassing 427 patients, dividing patient data into four groups by the treatment received: supportive care (92), SCS alone (276), SCS with IVIG (44), or cyclosporine (15). The mortality was 5.4% for supportive care, 8.0% for SCS, 13.6% for SCS with IVIG, and 0% for cyclosporine. Overall mortality was 7.7%. Adverse effects were most often attributed to SCS, including opportunistic infections and DRESS recurrence. Conclusion: Supportive care may be appropriate for mild DRESS cases. While SCS are commonly used, their effectiveness and safety remain a concern. IVIG, though typically used in severe cases, revealed higher mortality. Cyclosporine had favorable outcomes and could be a more suitable DRESS treatment. Prospective, randomized trials are needed to further evaluate treatment efficacy and guide clinical decision-making.