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Ebola, Global Health, Infectious Disease, Patient Care, Stanford News, Surgery

How to keep safe while operating on Ebola patients

How to keep safe while operating on Ebola patients

surgical instrumentsAmid the Ebola crisis, two U.S. surgeons with a combined 30 years of working in developing countries have stepped forward to help disseminate well-defined protocols for operating on any patient with the virus or at-risk of having contracting the virus.

In an op-ed piece published today in the San Jose Mercury News, the two surgeons first ask, then answer, their own question: “Why should anyone care about surgery and Ebola? Ebola is a virus.” Their answer is that patients still have accidents. They still need things like appendectomies and C-sections and treatment for gunshot wounds.

The piece points to shocking news reports like those of 16-year-old Shacki Kamara, a patient in Sierra Leone who died of gunshot wounds to his leg during the Ebola quarantine of West Point, Liberia because people were afraid to operate on him. The growing fear of operating on anyone suspected of having contracted the Ebola virus, which is transmitted by bodily fluids, is a flashback to the early days of the AIDS crisis when operating room personnel and physicians often declined to treat patients, said Stanford surgeon Sherry Wren, MD, who co-authored the op-ed with Johns Hopkins surgeon Adam L. Kushner, MD, founder and director of Surgeons OverSeas. The two wrote:

With supportive medical care, patients may survive an Ebola infection. Without surgery for severe trauma, obstructed labor, a strangulated hernia, or a perforated ulcer, some patients may die. The moral dilemma is overwhelming. How does one operate on a patient infected with Ebola, yet at the same time protect the surgical staff?

Last week, the two came together to write an Ebola surgery protocol and send it to a number of surgical organizations, and the largest one – the American College of Surgeons – immediately accepted and posted it on their website. The response to the new guidelines was immediate and overwhelming, Wren said. In Africa, 10 countries have since adopted the protocol. Press articles on the guidelines have also appeared around the world, including in the New York Times and Washington Post and on Al Jazeera. Wren told me in a phone interview that she was both a bit surprised and overwhelmed by the reaction:

I’ll tell you, it was amazing. I’ve seen very few things in surgery go that fast. There was a need to start the discussion. It was never my intent to be the definitive Ebola expert. I’ve never seen a case of Ebola in my life. We expanded existing  CDC guidelines for prevention of transmission of other infections such as HIV and hepatitis and then added common sense from years of  experience operating.

Both Wren and Kushner acknowledged the “unsung heroes” who bravely choose to treat Ebola patients and stress the importance of working to keep them as safe as possible by increasing the availability of supplies of protective gear especially in West Africa and working toward increased training for health care workers. As they state in their op-ed:

 The management of Ebola is new to many clinicians in the United States and elsewhere. We hope to see more training, protocols and personal protective supplies to lower risks to surgical staff and patients. Just as surgery is a necessary part of a functioning health system, surgery must be part of the discussion during this time of Ebola; otherwise, the death toll will not only include those unfortunate to have died from the virus but also those unlucky to have developed a treatable surgical condition in this time of Ebola.

Previously: Experience from the trenches in the first Ebola outbreak, Ebola: A look at what happened and what can be done, Paul Farmer: We should be saving Ebola patients, Ebola panel says 1.3 million cases possible, building trust key to containment and Should we worry? Stanford’s global health chief weighs in on Ebola
Photo by Badly Drawn Dad

Medical Education, Medicine and Society, Neuroscience, Science, Stanford News

Studying science at Stanford is a dream come true for one California man

Studying science at Stanford is a dream come true for one California man

new grad students

Tawaun Lucas grew up in Compton, East LA, a city with a reputation – whether deserved or not – for producing gangsters, not neuroscientists. It’s a reputation Lucas just ignored.

A high-school athlete who dreamed of playing  in the NFL or going to the Olympics, the 22-year-old instead joined this year’s entering class of neuroscience graduate students at Stanford with a new set of aspirations.

Dreams change, Lucas explained me when I interviewed him for a story I wrote about the 135 new bioscience graduate students starting the fall semester at Stanford. As I describe in the story:

Lucas only changed his aspirations from sports to science after being sidelined by injuries his sophomore year at California State University-Northridge, where he was on a scholarship as a track athlete. But starting Stanford’s neurosciences PhD program is a dream come true, he said. “Stanford was always my first choice,” he said. “I applied to 12 schools.” When he got the acceptance call from Stanford, he said he nearly dropped the phone. “I almost teared up and cried,” he said. “It was surreal. I can’t even describe the experience.”

Lucas’s mother worked as a bus driver for the Long Beach school district. His dad was a maintenance worker. No one in his family went to college, and he wasn’t a particularly good student in high school, so the path to studying neuroscience at Stanford was an unexpected one. But programs for underrepresented minorities in the sciences helped him along the way, as did his own fascination with human behavior and the study of the brain:

His interest in science didn’t develop until his undergraduate years. He was living at home at the time with his parents, working as a bank teller while attending Cal State Northridge.  He began to turn his energies to academics when athletics was no longer an option. “Once I figured out what I wanted to do, I became focused,” he said. He chose to study psychology because the environment he grew up in had sparked his curiosity about human behavior. “I grew up in an urban area around some pretty crazy people who made some pretty weird decisions,” he said. “I began to wonder why do people, say, raised in Compton or Watts, for example, make different choices than someone raised in, say, Manhattan Beach? Is it socioeconomic? Psychological? Is there a genetic element?

Anthony Ricci, PhD, a professor of otolaryngology and member of the Stanford Neurosciences Institute, who played a role in encouraging Lucas to apply to Stanford and is part of an institution-wide effort to encourage diversity in the sciences, emphasized just how important diversity is to future advances in science:

“A person’s background is really important to how they think about a problem,” Ricci said. “If everyone were white, middle-class, Harvard-trained, they might think too much alike. Science needs people who think differently.”

Previously: First-year science graduate students enter brave new world and No imposters here: Stanford grad students reassured as they begin school
Photo by Norbert von der Groeben

Medical Education, Medical Schools, Mental Health, Stanford News, Surgery

New surgeons take time out for mental health

New surgeons take time out for mental health

rope webI spent a recent morning watching about 30 Stanford surgical residents take time off from their operating rooms to participate in a series of team-building games out on the alumni lawn on campus. These are busy, dedicated professionals who are passionate about their work, so getting them to take time off is hard. “I can tell you a surgical resident would rather be in the operating room than anywhere else on earth,” Ralph Greco, MD, a professor of surgery, told me as he sat on a nearby bench watching the residents play games.

In a story I wrote about the games, I describe how the Balance in Life program, which sponsored the day’s event, was founded following the suicide of a former surgical resident, Greg Feldman, MD. Greco, who helped build the program, was committed to doing whatever he could to prevent any future tragedies like Feldman’s, as I explain in the piece:

“The residency program was just rocked to its knees,” he said, remembering back to the death in 2010 of the much-loved mentor and role model for  many of the surgical residents and medical students at the time. Feldman died after completing his surgical residency at Stanford and just four months into his vascular surgery fellowship at another medical center. “It was a very frightening time,” Greco said. “Residents were questioning whether they’d made the right choices.”

Today, the Balance in Life program includes, among other thing, a mentorship program between junior and senior residents, group therapy time with a psychologist and a well-stocked refrigerator with free healthy snacks. Residents themselves, like Arghavan Salles, MD, who participated in the ropes course, plan and coordinate activities:

“Some people think this is kind of hokie,” said Salles, who was one of a group of residents who helped found the program along with Greco following Feldman’s death. “Surgery is a super critical field,” Salles said. She paused to instruct a blind-folded colleague: “Step left! Step left!” “You face constant judgment in everything you do and say,” she added. “Everyone is working at the fringes of their abilities. They’re stressed.”

While writing this story, my co-workers suggested I read a September editorial in the New York Times that brought the issue into sharp focus. Spurred by the suicides two weeks prior of two second-year medical residents who jumped to their deaths in separate incidents in New York City, Pranay Sinha, MD, a medical resident at Yale-New Haven Hospital wrote about the unique stresses of new physicians:

As medical students, while we felt compelled to work hard and excel, our shortfalls were met with reassurances: ‘It will all come in time.’ But as soon as that MD is appended to our names in May, our self-expectations skyrocket, as if the conferral of the degree were an enchantment of infallibility. The internal pressure to excel is tremendous. After all, we are real doctors now.

Pranay’s message was similar to the one promoted by Stanford residents during the games: The key to battling new physician stress is realizing that you are not alone, that your colleagues are there to support you. “It sounds touchy feely to say that we care,” Salles told me. “But at the end of the day, if we want to have better patient care, we need to take care of each other too.”

Previously: Using mindfulness interventions to help reduce physician burnout and A closer look at depression and distress among medical students
Photo by Norbert von der Groeben

Aging, Health Policy, In the News, Medicine and Society

No one wants to talk about dying, but we all need to

No one wants to talk about dying, but we all need to

“Dying in America is harder than it has to be.”

That’s the headline of one of the stories published following the release of the Institute of Medicine’s 500-page report titled “Dying in America.” The report tackles head-on the difficult topic of how to provide individualized, appropriate care for patients with advanced serious illness in a country that is grappling with out-of-control health care costs.

Patients should, and can, take control of the quality of their life through their entire life, choosing how they live and how they die

Its conclusion: The system needs a major overhaul.

“Our current system is broken,” said David M. Walker, co-chair of the 21-member committee that authored the report and former U.S. Comptroller General from Bridgeport, Conn. “It does not result in the type of quality of care that people deserve and desire and it’s much more costly. Systematic changes are needed for more compassionate, affordable care.”

No easy solutions exist, the authors said at an hour-long press conference announcing the release of the report yesterday. Instead, they plan to spend the next year getting their message out to the public with far ranging goals for change: from more comprehensive coverage of palliative care by medical insurance, to more hours of palliative care education in medical and nursing schools, to improved communication between health care providers and their patients about their end-of-life care choices – along with a payer-system that reimburses for those conversations.

It’s a controversial topic that broke out into the public debate five years ago during the passage of the Affordable Care Act, when opponents of the bill claimed that a proposal for Medicare to reimburse doctors for counseling patients about living wills and advance directives would lead to bureaucrats setting up “death panels” to determine who deserved care.

But it’s also a topic that can no longer be ignored, authors of the report said. Too many Americans are suffering unnecessarily and as the elderly population continues to grow with the aging of the baby boom generation, these problems will continue to multiply.

“For most people, death does not come suddenly,” said Philip Pizzo, MD, co-author of the report and former dean of Stanford’s medical school, in an email to me discussing the conclusions of the report. “Instead, dying is a result of one or more diseases that must be managed carefully and compassionately over weeks, months, or even years, through many ups and downs.”

Physicians and other health care professionals can provide well-rounded care at the end of life to relieve patient pain, maximize functioning, alleviating emotional stress, and ease the burden of loved ones – all in a manner that is consistent with individual choices, he said.

“Patients should, and can, take control of the quality of their life through their entire life, choosing how they live and how they die,” Pizzo said.

But it’s not happening today.

“Studies show that doctors want to die in comfort at home at the end of life, but subject patients to high-intensity ineffective treatments,” he said. “Why?”

Previously: Study: Doctors would choose less aggressive end-of-life care for themselves, Former School of Medicine dean named to expert panel to reform end-of-life care in America, Communicating with terminally ill patients: A physician’s perspective and On a mission to transform end-of-life care

Medical Education, Medical Schools, Stanford News

Medical students start “transformational” journey

Medical students start "transformational" journey

With the help of Lars Osterberg MD, MPH, and Dr. Neil Gesundheit, MD. they give Brandon Turner  his official white coat at at the Stanford Medicine White Coat and Stethoscope Ceremony on Friday, August 22, 2014,at Stanford School of Medicine.  ( Norbert von der Groeben / Stanford School of Medicine )

The new school year has begun for students across the country, including Stanford’s 90 first-year medical students – who started class on Monday and spent last week at orientation activities anxious and excited for the  journey to finally begin.

To help the students prepare, faculty talked to them about the emotional and academic challenges of medical school and emphasized that it can be metamorphic and, not surprisingly, somewhat stressful. “They are seeing life and death,” said one faculty member at orientation, who added that medical school “is a transformational time the likes of which I don’t think you see in any other level of education.”

The week of preparation concluded with the traditional stethoscope ceremony, which I wrote about in an article published online today. The ceremony symbolizes the importance of the personal connection between doctor and patient, and during the event each student walks across the stage to accept their stethoscopes. As Laurie Weisberg, MD, president of the medical center alumni association, told the students:

The great thing about the stethoscope is you have to be close to your patient to use it. This is your chance to truly interact with the patient. You are listening to what the patient has to tell you.

In his address to the students, Dean Lloyd Minor, MD, told them the four-year, or longer, journey would change the way they see the world and that they “will learn some of life’s most valuable lessons from your patients.” He also highlighted some of the demographics of the new class:

Fifty-one percent of you are women; 15 percent of you are from communities underrepresented in medicine; 21 of you were born outside of the U.S., coming from China, Columbia, India, Vietnam, just to name a few. You come from a diverse and wide range of universities — 10 of you from Stanford, 13 from the Stanford of the East [Harvard]. Eighteen of you already have a master’s or a doctorate, and many of you have already published research, participated in varsity athletics, shined in the arts and contributed to your community.

Previously: Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicine, Top 10 reasons I’m glad to be in medical school and “Something old and something new” for Stanford medical students
Photo, of Brandon Turner receiving his official white coat at a ceremony last Friday, by Norbert von der Groeben

Medicine and Literature, Stanford News, Surgery

A surgeon battles her own unexpected complications

A surgeon battles her own unexpected complications

I first interviewed Stanford surgeon Sherry Wren, MD, a year and a half ago for an article about a course she taught to other surgeons on global health care. Based on her personal experience from medical missions to Chad, Congo and Ivory Coast, it was obvious the course was a labor of love. Here was a surgeon who was passionate about her work, and whose goal it was to overcome any and all obstacles to save patients – from using papaya paste for wound dressing to hand drills for relieving brain bleeds. She made use of a combination of her surgical skills, her physical strength and her love for her work to accomplish her goals. “You have no idea how physically hard it is to crank a six-millimeter pin into someone’s femur with a hand drill,” she told me then. “And I’m strong.”

When Wren mentioned off-hand that she was still recovering from post-surgical paralysis after her own neck surgery, I knew there was another story waiting to be told. Almost two years later, that story about Wren’s struggle to return to surgery following the partial paralysis of one of her most important tools, her left hand, has been published in Stanford Medicine magazine. My colleague Paul Costello referenced it here earlier this month.

This is a story about a surgeon experiencing what it’s like to be on the other side of the scalpel when something goes horribly wrong. In the piece, she describes what she felt upon waking up following neck surgery:

My left hand was like a claw. I couldn’t lift my left knee. Then my surgeon came to see me, and I recognized that ‘Oh shit!’ look on his face, because I’ve had that ‘Oh shit!’ look many times.”

Wren, who injured her spine following a deep-sea diving shipwreck, also talks of her struggle to return to the demanding, 10-14 hours surgeries that she excels at despite lingering damage to her left hand and the accompanying depression that blindsided her. I wrote:

It was the correct diagnosis. The correct treatment. There was no surgical error. And yet somehow, the veteran surgeon who makes a living with her hands woke up partially paralyzed. The unexpected complications included paralysis of her left hand and her left leg, and a weakened right hand. Already she thinks, Will I still be able to operate? Already she thinks, What am I if I’m not a surgeon?

This is Wren’s very personal story, one that she tells open and honestly. The experience of being the patient has made her a better physician, she said. And it’s a story that she hopes by telling, others can learn from.

“I thought a lot about whether I wanted to share this story,” Wren said. I, for one, am appreciative that she did.

Previously: Sherry Wren, MD – a surgeon’s road home, Surgery: Up close and personal, Stanford Medicine magazine opens up the world of surgery Surgery: Up close and personal and Stanford general surgeon discusses the importance of surgery in global health care

From August 11-25, Scope will be on a limited publishing schedule. During that time, you may also notice a delay in comment moderation. We’ll return to our regular schedule on August 25.

Aging, Health Policy, In the News, Public Health, Research, Stanford News

Study: Doctors would choose less aggressive end-of-life care for themselves

Study: Doctors would choose less aggressive end-of-life care for themselves

DNR bindersWhy do physicians continue to provide high-intensity care for terminally ill patients but choose to forgo such care for themselves at the end of life? That’s the question raised by a new Stanford study published in PLOS ONE today.

An overwhelming percentage of doctors surveyed for the study in 2013 – 88.3 percent to be exact – said they would choose “no-code” or do-not-resuscitate orders for themselves. And though other studies have shown that most other Americans would choose to die gently and naturally at home, that’s not what’s happening. As I describe in a release:

“A big disparity exists between what Americans say they want at the end of life and the care they actually received,” the study says. “More than 80 percent of patients say that they wish to avoid hospitalizations and high-intensity care at the end of life, but their wishes are often overridden.”

In fact, the type of treatments they receive depends not on the patients’ care preferences or on their advance directives, but rather on the local health-care system variables, such as institutional capacity and individual doctors’ practice style, according to the study.

The study involved two sets of subjects – 1081 physicians in 2013 and 790 physicians in 1989 – which both completed the same 14-question survey on their attitudes concerning advanced directives. Stanford researchers hypothesized that attitudes would have changed in the 24-years since the passage of the Self-Determination Act in 1990, a law designed to give patients more control over end-of-life care decisions and requires health care organizations to inform patients that they have the option to fill out such directives.

Surprisingly, despite the law, physicians attitudes have not changed, said VJ Periyakoil, MD, an expert in palliative care and lead author of the study. More from the release:

As a geriatrics and palliative care physician who sits at the bedside of sick patients herself, Periyakoil said she understands the disconnect between the type of care doctors want for themselves at the end of life and what they actually do for their patients. It’s not because doctors are trying to make more money or because they are intentionally insensitive to their patients’ desires. At the core of the problem is a biomedical system that rewards doctors for taking action, not for talking with their patients.

“Our current default is ‘doing,’ but in any serious illness there comes a tipping point where the high-intensity treatment becomes more of a burden than the disease itself,” said Periyakoil, who trains physicians in palliative medicine. “It’s tricky, but physicians don’t have to figure it out by themselves. They can talk to the patients and their families and to the other interdisciplinary team members, and it becomes much easier.

“But we don’t train doctors to talk or reward them for talking. We train them to do and reward them for doing. The system needs to be changed.”

A touching first-person essay on this topic by Ken Murray, MD, a retired family practitioner has been popping up recently on various blogs and other internet sites. It describes how doctors don’t want to experience the kind of suffering that they see their patients go through. In the piece, titled “How doctors die: It’s not like the rest of us, but it should be,” the author mentions that he has even seen one medical professional with a “Do not Resuscitate” tattoo.

Previously: Communicating with terminally ill patients: a physician’s perspective, Asking the hardest questions: Talking with doctors while terminally ill, On a mission to transform end-of-life care, The importance of patient/doctor end-of-life discussions and A Stanford nurse shares her experience in talking to her aging mother about end-of-life decisions
Photo by Frank DiBona

Medical Education, Medical Schools, Stanford News

Medical students take time to thank their patients

Medical students take time to thank their patients

thank you tree - smallWith their heavy academic workloads and the constant demand to keep up with the ever-growing body of medical literature, one might question whether medical students have time to learn and absorb the importance of developing the human connection vital to the doctor-patient relationship. Here’s something that provides strong evidence that they do: A group of fourth-year medical students here started a project to thank patients for being their most important teachers.

In today’s Inside Stanford Medicine, I write about the project, which featured 35 anonymous thank-you cards from medical students arranged into a display for the recent Medicine and the Muse Symposium. Some cards touch on life and death issues, some focus on the importance of hands-on medical training, and others express simple appreciation of the human bond. Reading over these heartfelt letters, it’s clear that the students recognize that the patient-doctor connection is key to their medical education. Here’s a sampling:

I will always remember that you asked me for an ice-cold Slurpee from 7-Eleven in broken words when you finally gained consciousness and spoke to me. I will never forget your gentle but firm nod expressing that you wouldn’t want artificial feedings prolonging your life… Taking care of patients like you and helping them in times of need makes medicine worthwhile… You taught me how to be a good physician and I will always remember you.”

Thank you to the patient with vasculitis and related short gut syndrome for sharing your physical pain as well as worried for the future with me. Thank you to the former physician with mental health concerns for teaching me humility. Thank you also to your families for teaching me about the impact of illness on your lives as well.

Thank you for reminding me why I chose to do medicine. For showing me that we can improve medical care further. For you and future patients.

Previously: Medical students and author Khaled Hosseini share their muse with Stanford community and Reality Check: When it stopped feeling like just another day in medical school
Photo by Jia Luo

Research, Stanford News, Stem Cells

Studying the inner ear and advancing research in developmental biology

Studying the inner ear and advancing research in developmental biology

hellerResearcher Stefan Heller, PhD, came to Stanford in 2005 from Harvard. His laboratory focuses on inner ear development and works on approaches to regenerate sensory hair cells, scarce sensory receptor cells that are essential for our senses of hearing and balance.

As I explained in an article about his arrival, Heller’s goal was to come here and collaborate with others to devise “a variety of possible cures for deafness from drug therapy treatment – which could be as simple as an application of ear drops-to stem cell transplantation into the inner ear to remedy hearing loss.” Since then, his lab has continued to add to the body of research on the inner ear’s early development and to pave the way towards regenerative therapies for hearing loss. The researchers’ most recent milestone (subscription required) – during which they designed the most detailed 3-D model to date of the otocyst, the embryonic structure in vertebrates that develops into the inner ear in the adult – was published online this month in the journal Cell.

In a video on the journal website, Heller and the lead author of the study, Robert Durruthy-Durruthy, a PhD candidate, describe the mathematical method used that allows the 3-D reconstruction of the developing inner ear. Russ Altman, PhD and Assaf Gottlieb, PhD, from Stanford bioengineering were collaborators of the study.

Heller recently described to me how microfluidics technology developed in the lab of Stanford bioengineering professor Stephen Quake, PhD, was essential to analyze single cells in order to develop the blue prints for their 3-D model. The approach is new in biology, Heller said. Much like dismantling the engine of a car into its smallest parts, taking apart a simple organ into single cells results in the challenge of putting the pieces back together.  “Our new method provides a good strategy for such reconstructions,” Heller said.

Heller also explained how this advancement will help as he continues researching early ear development and working on growing inner ear sensory hair cells, the linchpin for hearing. (Hair cells exist in limited numbers in human ears and once they are gone, hearing loss occurs.) He said:

This [paper] gives us deep insight into how this organ forms in early development. It identifies the different cell types and defines them in much more detail than previously known. It provides details about the inner ear progenitor cells that we are trying to generate from stem cells. Having this blue print will help us to generate sensory hair cells more efficiently and hopefully to regenerate hair cells at some time in the future.

The technology, Heller said, can also benefit others: “It can be used to reconstruct all kinds of things, other simple organs, perhaps even simple multicellular organisms, or structures like tumors.”

Previously: Regenerating sensory hair cells to restore hearing to noise-damaged ears, Stanford chair of otolaryngology discusses future regenerative therapies for hearing loss, Stefan Heller discusses stem cell research on Science Friday and Growing new inner ear cells a step toward a cure for deafness
Photo by Steve Fisch

Chronic Disease, Health Costs, Health Policy, Research, Stanford News

Keeping kidney failure patients out of the hospital

Keeping kidney failure patients out of the hospital

Keeping kidney patients healthy enough to stay out of the hospital certainly sounds like a good thing – both for the patients and the economy. Now there’s scientific evidence to show how this can be done.

Reducing hospital readmissions was a focus of the the Affordable Care Act, and Kevin Erickson, MD, an instructor in nephrology at Stanford, decided to study a group of patients who are often hospitalized. He and his colleagues examined whether an additional doctor’s visit in the month after hospital discharge would help keep kidney-failure patients on dialysis from being readmitted. He and his colleagues analyzed data collected between 2004-2009 by the United States Renal Data System, a national registry of nearly all end-stage renal disease patients in the country.

It’s nice to find something that may generate both cost savings and better health outcomes

Results showed that there was a significant reduction in hospital readmissions with that extra doctor’s visit in the month after hospital discharge. And while the percentage doesn’t sound all that significant – 3.5 percent -  in real numbers that translates to 31,370 fewer hospitalizations and $240 million per year saved, according to the study published this month in the Journal of the American Society of Nephrology.

“It’s nice to find something that may generate both cost savings and better health outcomes,” Erickson told me. “Patients with end-stage renal disease suffer from poor quality of life. Some of that I suspect is related to multiple trips in and out of the hospital.”

Patients with kidney failure are at a particularly high risk of hospital readmission: In 2009 patients getting dialysis were admitted to the hospital nearly two times per year, 36 percent of whom were rehospitalized within 30 days, according to the study.

Previously: Study shows higher Medicaid coverage leads to lower kidney failure rates; Study shows higher rates of untreated kidney failure among older adults; Study shows daily dialysis may boost patients’ heart function, physical health.

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