Audit of Early Mortality among Patients Admitted to the General Medical Ward at a District Hospital in Botswana

Background: Mortality among adult general medical admissions has been reported to be high across sub-Saharan Africa, yet there is a paucity of literature on causes of general medical inpatient mortality and quality-related factors that may contribute to the high incidence of deaths. Based on a prior study at our hospital as well as our clinical experience, death early in the hospitalization is common among patients admitted to the adult medical wards. Objective: Quantify early inpatient mortality and identify factors contributing to early in-hospital mortality of medical patients in a resource-limited hospital setting in Botswana. Methods: Twenty-seven cases of patients who died within 48 hours of admission to the general medical wards at Scottish Livingstone Hospital in Molepolole, Botswana from December 1, 2015–April 25, 2016 were retrospectively reviewed through a modified root cause analysis. Findings: Early in-hospital mortality was most frequently attributed to septic shock, identified in 20 (74%) of 27 cases. The most common care management problems were delay in administration of antibiotics (15, 56%), inappropriate fluid management (15, 56%), and deficient coordination of care (15, 56%). The most common contributing factors were inadequate provider knowledge and skills in 25 cases (93%), high complexity of presenting condition in 20 (74%), and inadequate communication between team members in 18 (67%). Conclusions: Poor patient outcomes in low-and middle-income countries like Botswana are often attributed to resource limitations. Our findings suggest that while early in-hospital mortality in such settings is associated with severe presenting conditions like septic shock, primary contributors to lack of better outcomes may be healthcare-provider and system-factors rather than lack of diagnostic and therapeutic resources. Low-cost interventions to improve knowledge, skills and communication through a focus on provider education and process improvement may provide the key to reducing early in-hospital mortality and improving hospitalization outcomes in this setting

AASLD Deepens Commitment to Diversity, Equity, and Inclusion

On June 2, 2020, the American Association for the Study of Liver Disease (AASLD) joined colleagues in gastroenterology in a joint statement condemning racism and injustice and pledging to lead change. This pledge offers a commitment to “continue to advocate for diversity in our staff and governance, grant awards to research health care disparities, ensure quality care for all, and work tirelessly to reduce inequalities in health care delivery and access.

Metformin and Hepatocellular Carcinoma

There is ample evidence that type 2 diabetes is an independent risk factor for the development of various cancers including hepatocellular carcinoma (HCC). Metformin, a widely used antidiabetic agent, has been shown to have chemopreventive properties that may reduce the risk of cancer in diabetes. Here we summarize clinical and experimental data concerning the role of metformin in diabetes-associated hepatocarcinogenesis and review the key molecular mechanisms implicated in this action. By modulating mitochondrial function, metformin activates adenosine monophosphateactivated protein kinase (AMPK), a master regulator of energy metabolism that corrects most diabetes-associated derangements and mitigates the impact of insulin resistance on tumor growth. Moreover, metformin acts through additional AMPK targets in various pathways of oncogenesis and tumor suppression. Finally, metformin may also hinder hepatocarcinogenesis through AMPK-independent mechanisms. Controversies about the use of metformin as a chemopreventive agent include an efficacy bias related to duration and severity of diabetes, a lack of convincing impact on nonalcoholic fatty liver disease (NAFLD) representing the liver manifestation of diabetes, and a disputed role in lactic acidosis as a major adverse event. Future research may help develop randomized clinical trials on the impact of HCC by metformin, explore its utility in the non-diabetic and noncirrhotic population, elucidate its precise mechanisms of action to identify new molecular targets, and evaluate safer and more efficient derivatives of this intriguing compound

Outcomes of a 3-Year Quality Improvement Study to Improve Advance Care Planning in Patients With Decompensated Cirrhosis.

INTRODUCTION: To report outcomes of a 3-year quality improvement pilot study to improve advance directive (AD) completion. METHODS: The pilot consisted of champions, education, electronic health record templates, and workflow changes. We assessed changes, predictors, and effects of AD completion. RESULTS: The pilot led to greater (8.3%-36%) and earlier AD completion, particularly among those divorced, with alcohol-associated liver disease, and with higher Model of End-Stage Liver Disease-Sodium score. Decedents whose AD specified nonaggressive goals experienced lower hospital lengths of stay. DISCUSSION: Advance care planning initiatives are feasible and may reduce health care utilization among decedents requesting less aggressive care