The Recovery of Consciousness via Evidence-Based Medicine and Research (RECOVER) Program: A Paradigm for Advancing Neuroprognostication.

Background: Neuroprognostication for disorders of consciousness (DoC) after severe acute brain injury is a major challenge, and the conventional clinical approach struggles to keep pace with a rapidly evolving literature. Lacking specialization, and fragmented between providers, conventional neuroprognostication is variable, frequently incongruent with guidelines, and prone to error, contributing to avoidable mortality and morbidity.

Recent Findings: We review the limitations of the conventional approach to neuroprognostication and DoC care, and propose a paradigm entitled the Recovery of Consciousness Via Evidence-Based Medicine and Research (RECOVER) program to address them.

Beyond the Question: Reexamining a Parent's Unusual Request.

Pediatricians sometimes think about medical ethics as the field of determining right and wrong in in answering difficult moral questions that occur at the bedside. But an emphasis on rapidly determining right and wrong when faced with ethical dilemmas can lead clinicians to miss important issues underlying both the question and their approach to answering it. We argue that ethical reflection is not merely a process of getting to the right answer but also a way to probe beyond the original question to better understand the stakeholders' perspectives and priorities.

Philadelphia Department of Health Doula Support Program: Early Successes and Challenges of a Program Serving Birthing People Affected by Substance Use Disorder.

Purpose: Maternal substance use and deaths due to overdoses are increasing nationwide. Evidence suggests that the rate of resumed substance use, and fatal and non-fatal overdose is greatest in the first year after birth, particularly around six months postpartum, compared to other parts of the perinatal period. Doula care has been linked to improvements in perinatal health and outcomes.

Connecting through Chaos: Stories of Empathy and Trust.

Multidisciplinary healthcare workers describe interactions with "difficult" patients that have shaped their lives and their clinical practice. The narrators recall navigating the push-pull of empathy and frustration to forge therapeutic patient relationships in inhospitable, under-resourced environments. Their stories offer glimpses into the traumatized people hiding behind "difficult" patient facades.

Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease.

For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use.

Racial and Socioeconomic Disparities in CKD in the Context of Universal Health Care Provided by the Military Health System.

Rationale & Objective: Health-impeding social determinants of health-including reduced access to care-contribute to racial and socioeconomic disparities in chronic kidney disease (CKD). The Military Health System (MHS) provides an opportunity to assess a large, diverse population for CKD disparities in the context of universal health care.

Study Design: Cross-sectional study.

Hospital nurses' moral distress and mental health during COVID-19.

Aims: To explore factors associated with nurses' moral distress during the first COVID-19 surge and their longer-term mental health.

Design: Cross-sectional, correlational survey study.

Methods: Registered nurses were surveyed in September 2020 about their experiences during the first peak month of COVID-19 using the new, validated, COVID-19 Moral Distress Scale for Nurses.

CKD Prevalence in the Military Health System: Coded Versus Uncoded CKD.

Rationale & Objective: Chronic kidney disease (CKD) is common but often goes unrecorded.

Study Design: Cross-sectional.

Setting & Participants: Military Health System (MHS) beneficiaries aged 18 to 64 years who received care during fiscal years 2016 to 2018.

Development and Validation of a Pragmatic Electronic Phenotype for CKD.

Background And Objectives: Poor identification of individuals with CKD is a major barrier to research and appropriate clinical management of the disease. We aimed to develop and validate a pragmatic electronic (e-) phenotype to identify patients likely to have CKD.

Design, Setting, Participants, & Measurements: The e-phenotype was developed by an expert working group and implemented among adults receiving in- or outpatient care at five healthcare organizations.

Need for a Judicious Use of Nonsteroidal Anti-inflammatory Drugs to Avoid Community-Acquired Acute Kidney Injury.

Millions of Americans use over-the-counter analgesics on a daily basis, and nearly 100 million nonsteroidal anti-inflammatory drug (NSAID) prescriptions are filled per year. In high-risk patients, these medications can disrupt kidney hemodynamics and precipitate community-acquired acute kidney injury (CA-AKI). The risk of NSAID-associated CA-AKI increases 3- to 5-fold in patients taking renin-angiotensin system inhibitors and diuretics concurrently.

Personalizing Longitudinal Care Coordination for Patients with Chronic Kidney Disease.

Chronic care coordination efforts often focus on the needs of the healthcare team and not on the individual needs of each patient. However, developing a personalized care plan for patients with Chronic Kidney Disease (CKD) requires individual patient engagement with the health care team. We describe the development of a CKD e-care plan that focuses on patient specific needs and life goals, and can be personalized according to provider needs.

Population Health for CKD and Diabetes: Lessons From the Indian Health Service.

Despite extensive clinical guidelines, innovative efforts to improve care, and well-funded efforts to raise awareness, limited progress has been made in reducing the burden of kidney disease in the United States, and the prevalence continues to increase worldwide. The Indian Health Service and the Centers for Disease Control and Prevention recently reported a 54% decrease in the incidence of kidney failure among American Indian and Alaska Native people with diabetes. This decrease in end-stage renal disease incidence was associated with a population health approach to diabetes care based in the community and the primary clinical setting.

Standardization of Urine Albumin Measurements: Status and Performance Goals.

Background: Urine albumin is a key laboratory test used for classification, assessment of risk, and monitoring treatment of patients with chronic kidney disease. Urine albumin measurement results are not standardized among different measurement procedures. Consequently, clinical guidelines using fixed decision values for urine albumin cannot be applied consistently.

Managing CKD by Telemedicine: The Zuni Telenephrology Clinic.

Telemedicine has significant potential to extend nephrology consultation to rural and isolated communities. We describe a telenephrology clinic that has delivered ongoing consultative care from a nephrologist based at the National Institutes of Health in Bethesda, MD, to the Zuni Comprehensive Health Center in western New Mexico. Over the past 9 years, the clinic has conducted 1870 patient visits managing patients using a collaborative approach engaging a nurse case manager, nephrologist, primary clinicians, pharmacists, and community health nurses.

CE: Improving Outcomes for Patients with Chronic Kidney Disease: Part 2.

: Coping with chronic kidney disease (CKD) is challenging for many people, since symptoms often don't appear until the disease is advanced and the patient is close to requiring dialysis. This two-part article aims to provide nurses with the basic information necessary to assess and manage patients with CKD. Part 1, which appeared last month, offered an overview of the disease, described identification and etiology, and discussed ways to slow disease progression.

CE: Improving Outcomes for Patients with Chronic Kidney Disease: Part 1.

: The burden of chronic kidney disease (CKD) is rising both in this country and worldwide. An estimated 10% to 15% of U.S.

Vital Signs: Decrease in Incidence of Diabetes-Related End-Stage Renal Disease among American Indians/Alaska Natives - United States, 1996-2013.

Background: American Indians and Alaska Natives (AI/AN) have the highest diabetes prevalence among any racial/ethnic group in the United States. Among AI/AN, diabetes accounts for 69% of new cases of end-stage renal disease (ESRD), defined as kidney failure treated with dialysis or transplantation. During 1982-1996, diabetes-related ESRD (ESRD-D) in AI/AN increased substantially and disproportionately compared with other racial/ethnic groups.

Social Determinants of Racial Disparities in CKD.

Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture.

Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care.

Patient education is associated with better patient outcomes and supported by international guidelines and organizations, but a range of barriers prevent widespread implementation of comprehensive education for people with progressive kidney disease, especially in the United States. Among United States patients, obstacles to education include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. For providers, lack of time and clinical confidence combine with competing education priorities and confusion about diagnosing CKD to limit educational efforts.

Association of Erythropoietin Dose and Route of Administration with Clinical Outcomes for Patients on Hemodialysis in the United States.

Background And Objectives: Recombinant human erythropoietin (epoetin) is used routinely to increase blood hemoglobin levels in patients with ESRD and anemia. Although lower doses of epoetin are required to achieve equivalent hemoglobin responses when administered subcutaneously rather than intravenously, standard practice has been to administer epoetin to patients on hemodialysis intravenously. Randomized trials of alternative epoetin treatment regimens in patients with kidney failure have shown that risks of cardiovascular complications and death are related to the dose levels of epoetin used.