Publications by authors named "Moises Auron"

25 Publications

  • Page 1 of 1

Liver dysfunction and SARS-CoV-2 infection.

World J Gastroenterol 2021 Jul;27(26):3951-3970

Departments of Hospital Medicine and Pediatric Hospital Medicine, Cleveland Clinic, Cleveland, OH 44195, United States.

Severe acute respiratory syndrome coronavirus 2 infection is the cause of coronavirus disease 2019 (COVID-19), which predominantly affects the respiratory system; it also causes systemic and multi-organic disease. Liver damage is among the main extrapulmonary manifestations. COVID-19-associated liver injury is defined as any liver damage occurring during the disease course and treatment of COVID-19 in patients with or without pre-existing liver disease, and occurs in approximately one in five patients. Abnormal liver test results have been associated with a more severe course of COVID-19 and other complications, including death. Mechanisms linking COVID-19 to liver injury are diverse. Particular consideration should be made for patients with pre-existing liver disease, such as metabolic dysfunction-associated fatty liver disease, chronic liver disease due to viral or autoimmune disease, liver transplant carriers, or cirrhosis, given the risk for more severe outcomes. This manuscript summarizes the current lines of evidence on COVID-19-associated liver injury regarding pathophysiology, clinical significance, and management in both patients with or without pre-existing liver disease, to facilitate clinicians' access to updated information and patient care. Finally, we mention the ideas and recommendations to be considered for future research.
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http://dx.doi.org/10.3748/wjg.v27.i26.3951DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8311530PMC
July 2021

Preoperative Pulmonary Risk Assessment.

Respir Care 2021 Jul;66(7):1150-1166

Department of Pulmonary & Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.

Postoperative pulmonary complications have a significant impact on perioperative morbidity and mortality and contribute substantially to health care costs. Surgical stress and anesthesia lead to changes in respiratory physiology, altering lung volumes, respiratory drive, and muscle function that can cumulatively increase the risk of postoperative pulmonary complications. Preoperative medical evaluation requires a structured approach to identify patient-, procedure-, and anesthesia-related risk factors for postoperative pulmonary complications. Validated risk prediction models can be used for risk stratification and to help tailor the preoperative investigation. Optimization of pulmonary comorbidities, smoking cessation, and correction of anemia are risk-mitigation strategies. Lung-protective ventilation, moderate PEEP application, and conservative use of neuromuscular blocking drugs are intra-operative preventive strategies. Postoperative early mobilization, chest physiotherapy, oral care, and appropriate analgesia speed up recovery. High-risk patients should receive inspiratory muscle training prior to surgery, and there should be a focus to minimize surgery time.
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http://dx.doi.org/10.4187/respcare.09154DOI Listing
July 2021

A Painful Coincidence?

J Hosp Med 2021 Jun;16(6):371-375

Department of Medicine, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn, New York.

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http://dx.doi.org/10.12788/jhm.3514DOI Listing
June 2021

Perioperative management of pregnant women undergoing nonobstetric surgery.

Cleve Clin J Med 2020 12 31;88(1):27-34. Epub 2020 Dec 31.

Assistant Professor of Obstetrics and Gynecology, West Virginia University Health Sciences Center, Morgantown, WV.

Nonobstetric surgery during pregnancy should be avoided if possible, but when surgery is required, an obstetrician should be part of the perioperative team. In general, preoperative assessment is similar regardless of whether a woman is pregnant, but cardiovascular, pulmonary, hematologic, and renal changes of pregnancy can increase surgical risk and must be taken into account. Special management considerations include pregnancy-associated laboratory changes, timing of surgery, anesthesia choice, intubation precautions, patient positioning, preoperative blood typing, intraoperative fetal monitoring, and venous thromboembolism prophylaxis.
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http://dx.doi.org/10.3949/ccjm.88a.18111DOI Listing
December 2020

The hospitalized patient with COVID-19 on the medical ward: Cleveland Clinic approach to management.

Cleve Clin J Med 2020 Nov 3. Epub 2020 Nov 3.

Chairman, Department of Hospital Medicine, Cleveland Clinic Community Care, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.

SARS-CoV-2-infected inpatients who are admitted to a noncritical care medical ward require a standardized approach that is based on evidence if available, and effective supportive and respiratory care. Outcomes are better when patients receive standardized care, in special COVID-19 wards in the hospital, from clinical teams with expertise. Available evidence and guidelines should be continuously appraised and integrated into clinical protocols for all domains of treatment, including isolation, and personal protective measures, pharmacologic therapy, and transitions of care. Inpatient pharmacologic therapy at this time consists primarily of dexamethasone and remdesivir, along with thromboprophylaxis, given the coagulopathy associated with COVID-19. This article summarizes current practices in our organization.
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http://dx.doi.org/10.3949/ccjm.87a.ccc064DOI Listing
November 2020

Blood management during the COVID-19 pandemic.

Cleve Clin J Med 2020 Aug 7. Epub 2020 Aug 7.

Section Head, Transfusion Medicine, Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic.

The worldwide COVID-19 pandemic has required healthcare systems to implement strategies for effective healthcare delivery while managing blood supply chain disruptions and shortages created by infection-limiting practices that have reduced blood donations. At Cleveland Clinic, we have made multiple synchronous efforts: a call for increased blood collection, alignment of efforts among transfusion medicine departments (blood banks), enhanced monitoring and triage of blood product use, and increased education on patient blood management practices regarding blood utilization and anemia management. In addition, we created an algorithm to assess anemia risks in patients whose elective surgery was cancelled to optimize preoperative hemoglobin levels.
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http://dx.doi.org/10.3949/ccjm.87a.ccc053DOI Listing
August 2020

Thrombolysis in children with COVID-19-associated pulmonary thromboembolism.

Gac Med Mex 2020 ;156(6):606

Department of Adult Hospital Medicine and Pediatrics, Pediatrics Institute, Cleveland Clinic, Cleveland, Ohio, USA.

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http://dx.doi.org/10.24875/GMM.M21000482DOI Listing
May 2021

Central Venous Line Associated Deep Vein Thrombosis in Hospitalized Children.

J Pediatr Hematol Oncol 2019 10;41(7):e432-e437

Cleveland Clinic Children's, Cleveland, OH.

An increase in the incidence of deep vein thrombosis (DVT) has been reported in pediatric patients over the past decade. The presence of central venous line (CVL) is a major contributing risk factor with conflicting data on the relative risk of DVT with various types of central lines. We aimed to assess the incidence of and identify potential risk factors for DVT overall and with different types of CVL individually. A retrospective chart review of pediatric patients with a CVL placed at Cleveland Clinic Children's from 2011 to 2016 was conducted. Data collected included demographics, potential risk factors, CVL characteristics and related thrombotic events. The study cohort consisted of 376 CVLs in 325 patients between 0 and 26 years of age. There were 1.6 thrombi per 10,000 line-days (95% confidence interval: 1.0, 2.5), and the overall incidence of DVT was 5.1%. The incidence of DVT was highest with tunneled catheters (5/16=31%) versus with peripherally inserted central catheters (4/111=3.6%) or with ports (10/249=4%, P<0.001), and whereas there were overarching significant risk factors for CVL-associated thrombi, these risk factors differed in significance when analyzed by the CVL type. The study supports the need for continued improvement in pediatric hospital practices for early identification of patients at a higher thrombosis risk.
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http://dx.doi.org/10.1097/MPH.0000000000001512DOI Listing
October 2019

Improving Documentation of Inpatient Problem List in Electronic Health Record: A Quality Improvement Project.

J Patient Saf 2018 Apr 19. Epub 2018 Apr 19.

Background: The problem list is critical in electronic documentation. It is a powerful tool for clinical decision-making because it provides a concise view of all patient problems in one place and is also a criterion for the Medicare meaningful use incentive program.

Objective: To measure the rate of utilization of problem list in electronic health records (EHR) in a pediatric hospital medicine unit and implement sequential interventions to increase the rate of use of problem list to more than 80% by the end of 2015, as measured by at least one documented hospital problem at discharge.

Methods: We performed a quality improvement process starting with a series of educational interventions. Gradual electronic changes were also made in our EHR to reach our goal.

Results: The use of the problem list for pediatric hospital medicine rose from 47% to 100% in June 2015 and continues to maintain well above the goal of 80%. The problem list usage throughout the children's hospital also rose to 100% within 9 months of project implementation.

Conclusions: Educational interventions and technology leveraging allowed us to achieve and sustain improvement in appropriate problem list usage.
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http://dx.doi.org/10.1097/PTS.0000000000000490DOI Listing
April 2018

Promoting High-Value Practice by Reducing Unnecessary Transfusions With a Patient Blood Management Program.

JAMA Intern Med 2018 01;178(1):116-122

Johns Hopkins Health System Blood Management Program, Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland.

Although blood transfusion is a lifesaving therapy for some patients, transfusion has been named 1 of the top 5 overused procedures in US hospitals. As unnecessary transfusions only increase risk and cost without providing benefit, improving transfusion practice is an effective way of promoting high-value care. Most high-quality clinical trials supporting a restrictive transfusion strategy have been published in the past 5 to 10 years, so the value of a successful patient blood management program has only recently been recognized. We review the most recent transfusion practice guidelines and the evidence supporting these guidelines. We also discuss several medical societies' Choosing Wisely campaigns to reduce or eliminate overuse of transfusions. A blueprint is presented for developing a patient blood management program, which includes discussion of specific methods for optimizing transfusion practice.
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http://dx.doi.org/10.1001/jamainternmed.2017.6369DOI Listing
January 2018

Routine Use of Postoperative Acid Suppression (GI Prophylaxis) in Non-Critically Ill Pediatric Appendectomy Patients.

Hosp Pediatr 2017 04 7;7(4):232-235. Epub 2017 Mar 7.

Cleveland Clinic Children's Hospital, Cleveland, Ohio; and

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http://dx.doi.org/10.1542/hpeds.2015-0115DOI Listing
April 2017

Parsimonious blood use and lower transfusion triggers: What is the evidence?

Cleve Clin J Med 2017 01;84(1):43-51

Chief, Department of Medicine, Hartford Hospital, Hartford, CT, USA.

Evidence supports a parsimonious approach to blood use for managing anemia, contrasting with the long-standing practice of blood transfusion targeting arbitrary hemoglobin levels. Hemodilution studies have demonstrated that humans can tolerate anemia. The cumulative data have confirmed and validated the safety of a conservative approach to transfusion. This has translated into formal national guidelines for blood transfusion as well as patient safety and quality markers supporting blood management stewardship to minimize unnecessary use of blood products.
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http://dx.doi.org/10.3949/ccjm.84a.15134DOI Listing
January 2017

Weighing Evidence and Art: A Challenging Case of Early-Onset Atypical Kawasaki Disease.

Hosp Pediatr 2015 Nov;5(11):591-6

Departments of Pediatrics, Pediatric Rheumatology, Cleveland Clinic Children's, Cleveland, Ohio.

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http://dx.doi.org/10.1542/hpeds.2014-0228DOI Listing
November 2015

When the dissociation curve shifts to the left.

Cleve Clin J Med 2015 Mar;82(3):156-60

Departments of Hospital Medicine and Pediatric Hospital Medicine, Cleveland Clinic.

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http://dx.doi.org/10.3949/ccjm.82a.14044DOI Listing
March 2015

Adrenal insufficiency.

Pediatr Rev 2015 Mar;36(3):92-102; quiz 103, 129

Department of Pediatric Endocrinology, Cleveland Clinic Children's, Cleveland, OH.

Adrenal insufficiency is a life-threatening condition that occurs secondary to impaired secretion of adrenal glucocorticoid and mineralocorticoid hormones. This condition can be caused by primary destruction or dysfunction of the adrenal glands or impairment of the hypothalamic-pituitary-adrenal axis. In children, the most common causes of primary adrenal insufficiency are impaired adrenal steroidogenesis (congenital adrenal hyperplasia) and adrenal destruction or dysfunction (autoimmune polyendocrine syndrome and adrenoleukodystrophy), whereas exogenous corticosteroid therapy withdrawal or poor adherence to scheduled corticosteroid dosing with long-standing treatment constitute the most common cause of acquired adrenal insufficiency. Although there are classic clinical signs (eg, fatigue, orthostatic hypotension, hyperpigmentation, hyponatremia, hyperkalemia, and hypoglycemia) of adrenal insufficiency, its early clinical presentation is most commonly vague and undefined, requiring a high index of suspicion. The relevance of early identification of adrenal insufficiency is to avoid the potential lethal outcome secondary to severe cardiovascular and hemodynamic insufficiency. The clinician must be aware of the need for increased corticosteroid dose supplementation during stress periods.
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http://dx.doi.org/10.1542/pir.36-3-92DOI Listing
March 2015

Postangioedema attack skin blisters: an unusual presentation of hereditary angioedema.

BMJ Case Rep 2014 Apr 10;2014. Epub 2014 Apr 10.

Department of Pulmonary and Critical Care, Cleveland Clinic, Cleveland, Ohio, USA.

Hereditary angioedema (HAE) is an autosomal dominant disorder characterised by attacks of self-limited swelling affecting extremities, face and intra-abdominal organs, most often caused by mutations in the C1-inhibitor gene with secondary Bradykinin-mediated increased vascular permeability. We describe a 36-year-old man with a history of HAE who presented with painful interdigital bullae secondary to an acute oedema exacerbation. Biopsy and cultures of the lesions were negative and they resolved spontaneously. It is important to highlight and recognise the development of oedema blisters after resolution of a flare of HAE (only 1 previous case report), and hence avoid unnecessary dermatological diagnostic workup and treatment.
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http://dx.doi.org/10.1136/bcr-2013-201482DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987241PMC
April 2014

Recognizing, managing medical consequences of eating disorders in primary care.

Cleve Clin J Med 2014 Apr;81(4):255-63

Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.

Eating disorders can lead to serious health problems, and as in many other disorders, primary care physicians are on the front line. Problems that can arise from intentional malnutrition and from purging affect multiple organ systems. Treatment challenges include maximizing weight gain while avoiding the refeeding syndrome.
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http://dx.doi.org/10.3949/ccjm.81a.12132DOI Listing
April 2014

Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value.

J Hosp Med 2013 Sep 19;8(9):486-92. Epub 2013 Aug 19.

Division of Quality and Safety, Geisinger Health System, Danville, Pennsylvania.

Background: In an effort to lead physicians in addressing the problem of overuse of medical tests and treatments, the American Board of Internal Medicine Foundation developed the Choosing Wisely campaign. The Society of Hospital Medicine (SHM) joined the initiative to highlight the need to critically appraise resource utilization in hospitals.

Methods: The SHM employed a staged methodology to develop the adult Choosing Wisely list. This included surveys of the organization's leaders and general membership, a review of the literature, and Delphi panel voting.

Results: The 5 recommendations that were subsequently approved by the SHM Board are: (1) Do not place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis). (2) Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for gastrointestinal complications. (3) Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms or active coronary disease, heart failure, or stroke. (4) Do not order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation. (5) Do not perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.

Conclusions: Hospitalists have many opportunities to impact overutilization of care. The adult hospital medicine Choosing Wisely recommendations offer an explicit starting point for eliminating waste in the hospital.
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http://dx.doi.org/10.1002/jhm.2063DOI Listing
September 2013

Blood management.

Anesthesiol Clin 2013 Jun;31(2):433-50

Division of Hospital Medicine, Hartford Hospital, Hartford, CT, USA.

Blood management is a system-based comprehensive approach that uses evidence-based medicine to facilitate an environment to encourage an appropriate use of blood products in the hospital setting. The ultimate goal of a blood-management program is to improve patient outcomes by integrating all available techniques to ensure safety, availability, and appropriate allocation of blood products. It is a patient-centered, multidisciplinary, multimodal, planned approach to the management of patients and blood products.
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http://dx.doi.org/10.1016/j.anclin.2013.02.001DOI Listing
June 2013

Right atrium tumor thrombus.

QJM 2013 Jul 26;106(7):679-80. Epub 2012 Jul 26.

Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.

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http://dx.doi.org/10.1093/qjmed/hcs135DOI Listing
July 2013

Rounding up the usual suspects.

J Hosp Med 2012 May-Jun;7(5):446-9. Epub 2012 Mar 9.

Department of Hospital Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.

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http://dx.doi.org/10.1002/jhm.1922DOI Listing
April 2013

Presumed premature ventricular contractions.

Cleve Clin J Med 2011 Dec;78(12):812-4

Department of Hospital Medicine, Cleveland Clinic, OH 44195, USA.

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http://dx.doi.org/10.3949/ccjm.78a.10155DOI Listing
December 2011

Inflammatory bowel disease: perioperative pharmacological considerations.

Mayo Clin Proc 2011 Aug;86(8):748-57

Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA.

The perioperative management of patients with inflammatory bowel disease is challenging given the altered immune system that results from a variety of biologic and immunomodulator therapies. Clinicians are often faced with challenges and complicated equations when deciding on the type and dose of medication. To understand the effect of these medications and review the evidence regarding the management of these medications in the perioperative setting, a PubMed-based literature search (January 1, 1960, through April 1, 2011) was conducted using the following search terms: perioperative management, risk, outcome, inflammatory bowel disease, ulcerative colitis, Crohn's disease, aminosalicylates, glucocorticoids, purine analogues, cyclosporine, methotrexate, biologic therapy, infliximab, and thromboembolism. The 414 articles identified were manually sorted to exclude those that did not address perioperative risk, outcomes, and medications in the abstracts, yielding 84 articles for review. Additional references were obtained from the citations within the retrieved articles. This review surveys the findings of the selected articles and presents guidelines and resources for perioperative medication management for patients with inflammatory bowel disease undergoing surgery.
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http://dx.doi.org/10.4065/mcp.2011.0074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146375PMC
August 2011

Renin-angiotensin system antagonists in the perioperative setting: clinical consequences and recommendations for practice.

Postgrad Med J 2011 Jul 25;87(1029):472-81. Epub 2011 Mar 25.

Department of Hospital Medicine, Cleveland Clinic, 9500 Euclid Ave, M2 Annex, Cleveland, OH 44195, USA.

There are no existing guidelines supporting the withdrawal or continuation of renin-angiotensin-aldosterone system (RAAS) antagonists in the preoperative setting. RAAS antagonists include ACE inhibitors, angiotensin II receptor subtype 1 blockers and direct renin inhibitors (eg, aliskiren), as well as the aldosterone antagonists. The use of these agents before surgery has been associated with a variable incidence of hypotension during the initial 30 min after induction of anaesthesia; however, these hypotensive episodes have not been conclusively linked to any significant postoperative complications, although recent data suggest an increase in postoperative morbidity and mortality in patients undergoing coronary artery bypass grafting. Further studies are required to be able to demonstrate if the organ-protective benefits of RAAS antagonists justify their continuation in the perioperative setting. Temporary withdrawal of RAAS antagonists in these patients may prevent or attenuate intraoperative hypotension and hypovolaemia. Alternatively, the increase in RAAS activity and blood pressure expected with cessation of RAAS antagonist therapy may impair regional circulation secondary to an increase in systemic vascular resistance. Full discussion of the potential implications of perioperative RAAS antagonist therapy with the surgical team is important, and strategies to ensure careful monitoring and maintenance of adequate intravenous volume before induction of anaesthesia are essential.
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http://dx.doi.org/10.1136/pgmj.2010.112987DOI Listing
July 2011

Stevens-Johnson and mycoplasma pneumoniae: a scary duo.

J Hosp Med 2010 Nov-Dec;5(9):567-8

Department of Hospital Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA.

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http://dx.doi.org/10.1002/jhm.664DOI Listing
April 2011
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