Summary Background Obesity increases the risk for venous thromboembolism (VTE), but whether high-dose thromboprophylaxis is safe and effective in morbidly obese inpatients is unknown. Objective To quantify the efficacy and safety of high-dose thromboprophylaxis with heparin or enoxaparin in inpatients with weight > 100 kilograms (kg) within the BJC HealthCare system. Patients/Methods In a retrospective cohort study, we analyzed 9241 inpatients with weight > 100 kg discharged from three hospitals in the BJC HealthCare system from 2010 through 2012. We compared the incidence of VTE in patients who received high-dose thromboprophylaxis (heparin 7500 units three times daily or enoxaparin 40 milligrams (mg) twice daily) to those who received standard doses (heparin 5000 units two or three times daily or enoxaparin 40 mg once daily). The primary efficacy outcome was hospital-acquired VTE identified by International Classification of Diseases (ICD)-9 diagnosis codes. The primary safety outcome was bleeding events identified by ICD-9 codes. Results Among the 3928 morbidly obese inpatients (weight > 100kg and body mass index (BMI) ≥ 40 kg/m2), high-dose thromboprophylaxis approximately halved the odds of symptomatic VTE (odds ratio (OR) 0.52, 95% CI 0.27-1.00; p-value (p) = 0.050). The rate of VTE was 1.48% (35/2369) in these morbidly obese inpatients who received standard doses of thromboprophylaxis, compared to 0.77% (12/1559) in those who received high doses. High-dose thromboprophylaxis did not increase bleeding (OR 0.84, 95% CI 0.66-1.07, p = 0.15). Independent predictors of VTE include surgery, male, cancer, and BMI. Conclusions High-dose thromboprophylaxis nearly halves the rate of VTE in morbidly obese inpatients.

If Bacillus subtilis is incubated in radioactive methionine in the absence of protein synthesis, the methyl-accepting chemotaxis proteins (MCPs) become radioactively methylated. If the bacteria are further incubated in excess nonradioactive methionine ("cold-chased") and then given the attractant aspartate, the MCPs lose about half of their radioactivity due to turnover, in which lower specific activity methyl groups from S-adenosylmethionine (AdoMet) replace higher specific activity ones. Due to the cold-chase, the specific activity of the AdoMet pool is reduced at least 2-fold. If, later, the attractant is removed, higher specific activity methyl groups return to the MCPs. Thus, there must exist an unidentified methyl carrier that can "reversibly" receive methyl groups from the MCPs. In a similar experiment, labeled cells were transferred to a flow cell and exposed to addition and removal of attractant and of repellent. All four kinds of stimuli were found to cause methanol production. Bacteria with maximally labeled MCPs were exposed to many cycles of addition and removal of attractant; the maximum amount of radioactive methanol was evolved on the third, not the first, cycle. This result suggests that there is a precursor-product relationship between methyl groups on the MCPs and on the unidentified carrier, which might be the direct source of methanol. However, since no methanol was produced when a methyltransferase mutant, whose MCPs were unmethylated, was exposed to addition and removal of attractant or repellent, the methanol must ultimately derive from methylated MCPs.

BACKGROUND Severe hypoglycemia (SH), defined as a blood glucose (BG) <40 mg/dL, is associated with an increased risk of adverse clinical outcomes in inpatients. OBJECTIVE To determine whether a predictive informatics hypoglycemia risk‐alert supported by trained nurse responders would reduce the incidence of SH in our hospital. DESIGN A 5‐month prospective cohort intervention study. SETTING Acute care medical floors in a tertiary care academic hospital in St. Louis, Missouri. PATIENTS From 655 inpatients on designated medical floors with a BG of <90 mg/dL, 390 were identified as high risk for hypoglycemia by the alert system. MEASUREMENTS The primary outcome was the incidence of SH occurring in high‐risk intervention versus high‐risk control patients. Secondary outcomes included: number of episodes of SH in all study patients, incidence of BG < 60 mg/dL and severe hyperglycemia with a BG >299 mg/dL, length of stay, transfer to a higher level of care, the frequency that high‐risk patient's orders were changed in response to the alert‐intervention process, and mortality. RESULTS The alert process, when augmented by nurse‐physician collaboration, resulted in a significant decrease by 68% in the rate of SH in alerted high‐risk patients versus nonalerted high‐risk patients (3.1% vs 9.7%, P = 0.012). Rates of hyperglycemia were similar on intervention and control floors at 28% each. There was no difference in mortality, length of stay, or patients requiring transfer to a higher level of care. CONCLUSION A real‐time predictive informatics‐generated alert, when supported by trained nurse responders, significantly reduced inpatient SH. Journal of Hospital Medicine 2014;9:621–626. © 2014 Society of Hospital Medicine

In Bacillus subtilis, addition of chemotactic attractant causes an immediate change in distribution of methyl groups on methyl-accepting chemotaxis proteins (MCPs), whereas in Escherichia coli, it causes changes that occur throughout the adaptation period. Thus, methylation changes in B. subtilis are probably related to excitation, not adaptation. If labeled cells are exposed to excess nonradioactive methionine, then attractant causes immediate 50% delabeling of the MCPs, suggesting that a flux of methyl groups through the MCPs occurs. Methanol is given off at a high rate during the adaptation period and probably reflects demethylation of some substance to bring about adaptation. The fact that many radioactive methyl groups are lost immediately from the MCPs but only slowly arise as methanol is consistent with the hypothesis that they are transferred from the MCPs to a carrier from which methanol arises. Demethylation of this carrier may cause adaptation.

BACKGROUNDPhysician recognition of chronic kidney disease (CKD) in elderly patients has been noted to be poor. These patients are at increased risk of medication dosing errors and acute renal failure.OBJECTIVETo investigate the effect of reporting estimated glomerular filtration rate (GFR) of elderly hospitalized patients on physician recognition of CKD and physician prescribing behaviors.DESIGNA retrospective combined with a prospective medical record review project.SETTINGA large academic medical center.PATIENTSPatients included were 65 years of age or older and had creatinine values within the normal laboratory range (< 1.6 mg/dL).INTERVENTIONReporting a calculated estimate of GFR to physicians.MEASUREMENTSRates of recognition of CKD were examined before and after the intervention. The effects of the intervention on prescription of renal‐dosed antibiotics and nonsteroidal anti‐inflammatory drugs (NSAIDS) and cyclooxygenase‐ 2 inhibitors (COX‐2) at hospital discharge were assessed.RESULTSA total of 260 and 198 patients were included before and after the intervention, respectively. Recognition of chronic kidney disease was low in both groups but demonstrated a significant increase following reporting of estimated GFR (3.9% to 12.6%, P < .001). Reporting of GFR was not associated with a significant decrease in prescription of NSAID/COX‐2 medications or increased rates of correct dosing of antibiotics (P = .10 and P = .81, respectively).CONCLUSIONSAlthough reporting of estimated GFR was associated with improved physician recognition of CKD in elderly hospitalized patients, it did not lead to a change in physician prescribing. More extensive interventions are necessary to increase recognition and decrease medication dosing errors. Journal of Hospital Medicine 2007;2:74–78. © 2007 of Hospital Medicine.