Acute kidney injury in the setting of ascites and cirrhosis is a medical emergency characterized by significant morbidity and mortality. Clinicians other than gastroenterologists are often the front line against acute kidney injury for patients with ascites. Owing to the specifics of cirrhotic physiology, the treatment and prevention of acute kidney injury in the setting of ascites has unique features, widespread knowledge of which will benefit our patients with cirrhosis. Early detection and treatment of infection, maximization of cardiac output, and avoidance of medications that limit cardiorenal adaptations to arterial underfilling are part of a multipronged strategy to protect the renal function of our patients with cirrhosis and ascites.

Endocrine disrupting chemicals (EDCs) are defined as exogenous chemicals, or mixtures of chemicals, that can interfere with any aspect of hormone action. The field of endocrine disruption is historically rooted in wildlife biology and reproductive endocrinology, where EDCs are demonstrated contributors to infertility, premature puberty, endometriosis, and other disorders. Recently, EDCs have been implicated in metabolic syndrome and obesity. Adipose tissue is a true endocrine organ and therefore highly susceptible to disturbance by EDCs. Obesogens, a subset of EDCs, promote adiposity by altering programming of fat cell development, increasing energy storage in fat tissue, and interfering with neuroendocrine control of appetite and satiety. Obesity adds more than $200 billion to US healthcare costs and the number of obese individuals continues to increase. Hence, there is an urgent, unmet need to understand the mechanisms underlying how exposures to certain EDCs may predispose the population to be obese. The authors of this review discuss the history of obesogen discovery from its origins in reproductive biology to its latest role in the transgenerational inheritance of obesity in mice. They discuss the development of adipose tissue in an embryo, maintenance of adipocyte number in adults, how EDC disruption programs stem cells to preferentially make more adipocytes, the mechanisms by which chemicals can permanently alter the germline epigenome, and whether there are barriers to EDCs in the gametes.

Exposure to childhood adversity is associated with negative long-term health and economic outcomes, but little is known about how adversity exposure in parents' early lives may affect their children's food security. This study investigated the association between female caregivers' adverse childhood experiences (ACEs) and household and child food insecurity. Caregivers reporting both depressive symptoms and four or more ACEs, compared with those reporting no depressive symptoms and no ACEs, were 12.3 times as likely to report low food security, 28.8 times as likely to report very low food security, and 17.6 times as likely to report child food insecurity. (Available for CME credit.)

Medications that block the renin-angiotensin system (RAS) are among the best-studied agents for slowing the progression of kidney disease; however, the relative effects of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) remain unclear. In this month's AJKD, Xie et al present a systematic review of 119 randomized controlled trials involving a total of 64,768 participants with chronic kidney disease. ACE inhibitors and ARBs reduced the odds of kidney failure by 39% and 30%, respectively, compared with placebo. ACE inhibitors were also associated with higher probabilities of reducing both cardiovascular and all-cause death.

For elderly persons who become fatigued when walking, what is the fall risk? Researchers from Virginia found that increased age brought slower gait speed, decreased lower leg strength, slowed reaction time, and increased fall risk. A noticeable difference in fall risk was seen in the oldest age group (70 to 79 year olds). Because most falls happen when an elderly person is moving about while performing activities of daily living, such as walking, further assessing these parameters could give more insight.

This study demonstrates a significant effect of mindfulness meditation on working memory capacity in adolescents. Mindfulness interventions may be feasibly abridged, while still delivering important benefits.

Most extremely preterm infants have biochemical vitamin D deficiency at birth, but the optimal dose of vitamin D supplementation to achieve biochemical vitamin D sufficiency is not known. This randomized controlled pilot trial suggests that initial higher doses (800 IU/d) for a shorter duration (1 to 2 weeks) to restore serum vitamin D concentrations to the normal range, followed by a lower dosage (200 IU/d), may be ideal. A large randomized trial assessing multiple clinical outcomes is required to determine whether such dosing decreases the risk of lung disease or late onset sepsis in extremely preterm infants.

Researchers who looked at 184,000 outpatient visits in 2010-2011 found that about 30% of prescriptions for antibiotics were unnecessary overall, and about half of those written for acute respiratory conditions were not needed. Experts said doctors should focus less on what patients expect and more on what they need. "If we know that an antibiotic is really not likely to make people feel better, we still can provide alternatives for symptom relief that will help people feel better," said Dr. Sara Cosgrove, who wrote an editorial that accompanied the study in the Journal of the American Medical Association.

The US Preventive Services Task Force issued draft guidelines that say there isn't enough evidence to recommend widespread celiac disease screening and more research is needed on the benefits of testing asymptomatic adults. Dr. Joseph Murray, who helped write celiac disease screening guidelines for the American College of Gastroenterology, said the most controversial aspect of the report is the failure to recommend screening for people who have a close relative with celiac disease or those at higher risk due to diabetes.

Hospitals and health systems are experimenting with new risk-based reimbursement models linked to quality as they develop accountable care organizations. Leadership support and having a health care delivery system that recognizes the value of quality are important factors in creating a successful risk-based strategy, said Montefiore Health System senior vice president Stephen Rosenthal.

Hospital medicine is 20 years old and the number of hospitalists has reached 52,000, making it "the fastest-growing specialty of all time," said Laurence Wellikson, M.D., chief executive of the Society of Hospital Medicine. Robert Wachter, M.D., who first used the term "hospitalist," said the job is similar to an orchestra conductor because it manages patients, specialists and staff in a team-based setting.

A study in Health Affairs showed 231 hospitals got bonus payments through the Hospital Value-Based Purchasing program because their Medicare patient costs were less than at other facilities, even though they had below-average quality scores. The CMS said it will consider changing the program so hospitals scoring below the national median in quality would not get bonuses.

A calorie-restricted diet led to weight loss and a significant improvement in quality of life over two years for people who were mildly overweight or at a healthy weight, compared with a group that did not diet, according to a study in JAMA Internal Medicine. Researchers said weight loss leads to biological changes, such as lower blood glucose or cholesterol levels, that may result in a happier life, even for people who are not overweight.