The cardiac arrest survival score: A predictive algorithm for in-hospital mortality after out-of-hospital cardiac arrest

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is associated with high mortality. Current methods for predicting mortality post-arrest require data unavailable at the time of initial medical contact. We created and validated a risk prediction model for patients experiencing OHCA who achieved return of spontaneous circulation (ROSC) which relies only on objective information routinely obtained at first medical contact.

METHODS

We performed a retrospective evaluation of 14,892 OHCA patients in a large metropolitan cardiac arrest registry, of which 3952 patients had usable data. This population was divided into a derivation cohort (n = 2,635) and a verification cohort (n = 1,317) in a 2:1 ratio. Backward stepwise logistic regression was used to identify baseline factors independently associated with death after sustained ROSC in the derivation cohort. The cardiac arrest survival score (CASS) was created from the model and its association with in-hospital mortality was examined in both the derivation and verification cohorts.

RESULTS

Baseline characteristics of the derivation and verification cohorts were not different. The final CASS model included age >75 years (odds ratio [OR] = 1.61, confidence interval [CI][1.30-1.99], p < 0.001), unwitnessed arrest (OR = 1.95, CI[1.58-2.40], p < 0.001), home arrest (OR = 1.28, CI[1.07-1.53], p = 0.008), absence of bystander CPR (OR = 1.35, CI[1.12-1.64], p = 0.003), and non-shockable initial rhythm (OR = 3.81, CI[3.19-4.56], p < 0.001). The area under the curve for the model derivation and model verification cohorts were 0.7172 and 0.7081, respectively.

CONCLUSION

CASS accurately predicts mortality in OHCA patients. The model uses only binary, objective clinical data routinely obtained at first medical contact. Early risk stratification may allow identification of more patients in whom timely and aggressive invasive management may improve outcomes.

Dose effect of patient-care team communication via secure portal messaging on glucose and blood pressure control

Objectives

Organizational strategies for implementing eHealth tools influence patient and provider use of portal technology. This study examines whether the intensity of bidirectional secure portal messaging is associated with improved clinical outcomes.

Material and Methods

This is a retrospective cohort analysis of 101 019 patients with diabetes or hypertension (11 138 active portal users) who received primary care within the Ochsner Health System between 2012 and 2014. Propensity score-adjusted multivariable fixed effects regression panel analysis was used to examine associations between intensity of "medical advice" portal messaging and glucose/blood pressure control.

Results

Most portal users rarely used medical advice messaging. A higher proportion of patients who were age 50 years and older, female, white non-Hispanic, and with co-morbid diabetes and hypertension had higher frequency and intensity of medical advice messaging. Study findings revealed a dose-response effect of the intensity of messaging on glucose control, whereby, compared to nonportal users, each level of messaging among portal users was associated with greater decreases in HbA1c (β estimate [95% CI]: none -0.28 (-0.34 to -0.22); low -0.28 (-0.32 to -0.24); medium -0.41 (-0.52 to -0.31); high -0.43 (-0.60 to -0.27), all P ≤ .001). There was no observed effect on blood pressure.

Conclusions

The digital divide exists not only between portal users and nonusers but also among portal users. Research exploring the relationship between intensity of bidirectional secure messaging and health outcomes for a broader scope of chronic conditions is needed. Future implementation research must also elucidate best practices that enhance not only the use of portals by patients and providers, but how they use portals.

Von Willebrand Factor Drives the Association Between Elevated Factor VIII and Poor Outcomes in Patients With Ischemic Stroke

Background and Purpose—

Despite clear roles of factor VIII (FVIII) and von Willebrand factor (vWF) in thrombosis, few studies have examined the relationship of these factors with acute ischemic stroke (AIS). We sought to determine whether concurrent elevation in FVIII and vWF was associated with adverse events and outcomes.

Methods—

From our prospective stroke registry, patients consecutively admitted with AIS between July 2008 and October 2013 were included if both FVIII and vWF were measured during admission. The primary outcome was the modified Rankin Scale score on discharge.

Results—

Among 1453 cases in our stroke registry, 148 patients with AIS met inclusion criteria; 62 patients (41.9%) had FVIII−/vWF−, 16 patients (10.8%) had FVIII+/vWF−, and 51 patients (34.5%) had FVIII+/vWF+. In the fully adjusted model, patients with FVIII+/vWF+ had increased odds of inpatient complications (odds ratio, 8.6; 95% confidence interval, 1.58–46.85; P =0.013) and neuroworsening (odds ratio, 3.2; 95% confidence interval, 1.18–8.73; P =0.022) than patients with FVIII−/vWF−. Adjusted for age, baseline stroke severity, and glucose, patients with FVIII+/vWF+ had increased odds of poor functional outcome (modified Rankin Scale>2; odds ratio, 2.87; 95% confidence interval, 1.16–7.06; P =0.021) than patients with FVIII−/vWF−.

Conclusions—

Concurrent FVIII/vWF elevation predicts higher odds of inpatient complications, neuroworsening, and worse functional outcomes for patients with AIS compared with patients with normal levels. Our findings suggest that FVIII and vWF levels may serve as clinically useful stroke biomarkers by providing risk profiles for patients with AIS.

Concomitant thyroid disease and primary hyperparathyroidism in patients undergoing parathyroidectomy or thyroidectomy

BACKGROUND

Thyroid abnormalities have been found intraoperatively during parathyroidectomy and have resulted in concomitant thyroidectomy. The identification of concomitant disease is important prior to primary operation in order to minimize reoperations. This study investigates the incidence of concomitant primary hyperparathyroidism (PHPT) and thyroid nodular disease in patients undergoing thyroidectomy or parathyroidectomy.

METHODS

We performed a retrospective review of prospectively gathered data for 621 patients who underwent thyroidectomy, parathyroidectomy, or both at Tulane Medical Center. Information obtained included initial referral, initial thyroid stimulating hormone (TSH), initial parathyroid hormone (PTH), fine needle aspiration (FNA) results, ultrasound results, type of operation performed, final diagnosis, and final pathology.

RESULTS

Among the 400 patients referred primarily for thyroid disease, 13.50% underwent a thyroidectomy and parathyroidectomy (PTX) simultaneously and 10.75% received a final diagnosis of thyroid and concomitant parathyroid disease. Among the 103 patients referred primarily for parathyroid disease, 26.21% underwent a PTX and thyroidectomy and 24.27% received a final diagnosis of both thyroid and parathyroid disease. Patients referred primarily for parathyroid disease were more likely to receive a final diagnosis of both parathyroid and thyroid disease and were more likely to undergo a combined operation.

CONCLUSIONS

Concomitant thyroid and parathyroid disease occur and preoperative analysis is important to avoid increased complications from reoperations.

Do anticoagulation medications increase the risk of haematoma in ultrasound-guided fine needle aspiration of thyroid lesions?

BACKGROUND

A feared complication of thyroid fine needle aspiration (FNA) is bleeding diathesis and haematoma at the biopsy site. Patients are often advised to discontinue antithrombotic/anticoagulant (AT/AC) medications prior to the procedure. The aim of this study was to examine the risk of bleeding in patients on AT/AC medications undergoing cervical ultrasound (US)-guided FNA.

METHODS

A retrospective chart review of 803 patients who underwent US-guided FNA of thyroid nodules over 8 years by a single endocrine surgeon was undertaken. Clinical variables, patient demographics and use of AT/AC medications were collected and analysed. The principle outcome measures included the incidence of procedure-related haematoma formation. Multivariable logistic regression was used to investigate the possible independent association between post-FNA haematoma and anticoagulation, adjusting for age, African American race, body mass index, vascularity and lesion size.

RESULTS

A total of 1568 lesions were included in 803 patients. The mean age for the patients on AT/AC was 63.0 ± 10.4 years and those not on AT/AC was 50.1 ± 14.2 years (P < 0.001). Of those, 148 patients had 336 lesions (21%) biopsied while taking one or more daily AT/AC agent (81 patients: aspirin; 11 patients: Plavix; 17 patients: aspirin and warfarin; 30 patients: aspirin and Plavix; seven patients: rivaroxaban and aspirin; and two patients: ticagrelor and aspirin). Three patients (0.89%) in the AT/AC group compared to six patients (0.49%) not receiving AT/AC medications developed a haematoma (P = 0.41). All complications were treated conservatively and none required intervention.

CONCLUSIONS

US-guided FNA of thyroid lesions can be safely performed on patients taking AT/AC including newer agents, without an increase in adverse outcomes or decreased diagnostic rate. Further larger prospective multi-institutional studies are warranted to further investigate this important finding.

Can Suspicious Ultrasound Features Predict BRAFV600E Status in Papillary Thyroid Cancer?

BACKGROUND

Papillary thyroid carcinoma (PTC) can be predicted from certain suspicious ultrasound (US) features of thyroid nodules. The aim of this study was to examine if these suspicious features can predict the more aggressive PTC associated with B-type Raf kinase (BRAFV600E) mutation.

METHODS

This was a retrospective review of prospectively collected data on patients with PTC and known BRAFV600E status. All patients underwent preoperative US by the same surgeon who performed all the operations. We divided patients into BRAFV600E positive and negative groups. All ultrasonographic data were collected including nodule size, echogenicity, solid or cystic nature, presence of calcifications, irregular margins, and internal vascularity.

RESULTS

Of 141 patients with PTC, BRAFV600E mutation was detected in 48 (34.0$) patients. There was no significant difference in nodule size (2.06 cm ± 1.37 vs. 2.15 cm ±1.55, p = 0.75) between BRAFV600E positive and negative groups. BRAFV600E positivity was associated with higher rates of -hypoechogenicity (57.5$ vs. 36.6, p = 0.02), calcifications (48.9 vs. 19.4$, p < 0.01), and irregular margins (21.3 vs. 6.5$, p < 0.01). There was no significant difference in the noncystic nature or internal vascularity between BRAFV600E positive and negative groups. The presence of all suspicious US features is associated with a positive predictive value of 100.0$. In the absence of all suspicious features, the negative predictive value was 84.2$. When suspicious lymph nodes (LNs) detected by preoperative US were compared, there was no significant difference between BRAFV600E positive and negative groups (30.6 vs. 21.7$, p = 0.35).

CONCLUSION

The presence of multiple suspicious US findings of thyroid nodules can predict the BRAFV600E mutation status of papillary thyroid cancer nodules. The highest accuracy overall (93.2$) was achieved by combining calcification, irregular margins, and hypoechogenicity with extrathyroidal extension and LN metastasis. Future multi-institutional studies are warranted to help surgeons with risk stratification and operative planning for patients with papillary thyroid cancer.

Does Distance to Treatment Affect Mortality Rate for Surgical Oncology Patients?

INTRODUCTION

Using the National Cancer Database (NCDB), we seek to analyze the relationship of patient distance to hospital of treatment on mortality trends after surgery, since patients often travel large distances to referral centers.

METHODS

A retrospective cohort study of the NCDB from 2004 to 2013 was performed, and patients with gastrointestinal, melanoma, and head and neck primary site tumors who underwent surgery were included. We excluded cases with no recorded mortality status or distance from the hospital. A multivariable logistic regression was conducted with adjustments for population density, treating facility location, age, race, gender, education, income, insurance, comorbidities (Charlson-Deyo score), days from diagnosis to treatment, positive margin, tumor stage and grade, and lymph or vascular invasion.

RESULTS

A total of 1 424 482 patients were included. Overall median distance to hospital was 9.7 miles (range 4.2-23.7 miles); 696 647 (48.91%) of the sample traveled a distance greater than 10 miles to the institution where the procedure was performed. The multivariable regression analysis demonstrated overall lower mortality for those patients travelling a longer distance to care for multiple tumor types, including: liver (OR .87, .77-.99, P = .032), pancreas (OR .82, .76-.89, P < .001), colon (OR .92, .89-.95, P < .001), rectum (OR .90, .83-.96, P = .003), melanoma (OR .83, .79-.88, P < .001), and tumors of the larynx (OR .80, .69-.94, P = .005).

DISCUSSION

Increased distance traveled for surgical treatment has a significant correlation with decreased odds of mortality for multiple cancers, highlighting the importance of centralized referral patterns for oncology care.

Development and Evaluation of a Nutrition-Centered Lifestyle Medicine Curriculum for Physician Assistant Students

BACKGROUND

US medical schools are increasingly integrating lifestyle medicine competencies into their academic programs. Yet, physician assistant (PA) academic programs have been slower to respond.

METHODS

We developed, implemented, and evaluated a nutrition-centered lifestyle medicine curriculum for 2nd-year PA students (n = 24). The 4-week hybrid, 2-credit hour course activities aligned with the American College of Lifestyle Medicine competencies for primary care providers and reinforced four of the Accreditation Standards for PA Education. We combined didactic lectures with weekly hands-on cooking modules from the "Health meets Food" courseware for medical students. We employed a pre-post evaluation design including a comparison group of 2nd-year PA students in a separate program. We assessed changes in personal nutrition behaviors and knowledge and confidence for counseling in nutrition, exercise/physical activity, weight, smoking, and alcohol, using the modified 5A's framework (assess, advise, agree, assist, and arrange) for lifestyle counseling.

RESULTS

Students receiving the intervention demonstrated significantly higher gains in both knowledge and confidence for the 5A's of nutrition counseling compared to the control group. Self-reported knowledge and confidence for the 5A's of counseling for the other lifestyle behaviors similarly improved among the intervention group compared to the control group, but to a lesser extent.

CONCLUSION

A nutrition-centered lifestyle medicine course can demonstrate PA academic program adherence to accreditation standards, while also introducing students to nutrition and lifestyle medicine competencies. Hands-on experiences that reinforce didactic instruction may maximize student knowledge and self-efficacy for implementing lifestyle medicine into their practice.

Complex Left Atrial Appendage Morphology Is an Independent Risk Factor for Cryptogenic Ischemic Stroke

Importance: Ischemic strokes pose a significant health burden. However, the etiology of between 20 and 40% of these events remains unknown. Left atrial appendage morphology may influence the occurrence of thromboembolic events. Design: A retrospective cross-sectional study was conducted to investigate the role of LAA morphology in patients with atrial fibrillation (AF) and cardioembolic-associated stroke and patients with cryptogenic stroke without atrial fibrillation. LAA morphology is classified into two groups: (1) simple (chicken-wing) vs. (2) complex (non-chicken wing) based on transesophageal echocardiography (TEE) findings. In addition to the LAA morphology, left atrial parameters, including orifice diameter, depth, emptying velocity, and filling velocity, were collected for both groups. Mathematical, computational models were constructed to investigate flow velocities in chicken-wing and non-chicken wing morphological patterns to assess LAA function further. Findings: TEE values for volume, size, emptying, and filling velocities were similar between simple and complex LAA morphology groups. Patients with cryptogenic stroke without coexisting AF were noted to have significantly higher rates of complex LAA morphology. Chicken-wing LAA morphology was associated with four-fold higher flow rate (kg/s) in computational simulations. Conclusions: Complex LAA morphology may be an independent contributing factor for cryptogenic strokes. Further studies are warranted to investigate the mechanism involved in LAA morphology and thromboembolic events.

Bioprosthetic valve monitoring in patients with carcinoid heart disease

Background

Carcinoid heart disease (CnHD) is a frequent cause of morbidity and mortality in patients with neuroendocrine tumors and carcinoid syndrome. Although valve replacement surgery appears to decrease all-cause mortality in patients with advanced CnHD, few studies have investigated the outcomes of patients after valve replacement.

Methods

We conducted a multi-institution retrospective registry of patients who received both tricuspid and pulmonic bioprosthetic valve (TV/PV) replacements for advanced CnHD from November 2005 to March 2021. Patients were followed post-operatively with echocardiographic studies every 3 months. Carcinoid valvular heart disease scores were used to monitor valve degeneration. Neuroendocrine tumor treatment, their administration times, and associations with echocardiographic findings were recorded.

Results

Of 87 patients with CnHD, 22 patients underwent simultaneous surgical TV and PV replacement. In 6 patients (27.3%), increased PV V_max was the first echocardiographic manifestation of valve degeneration in the setting of occult neurohormonal release. Post-operative telotristat ethyl and peptide receptor radionuclide therapy appeared to stabilize PV V_max. The PV V_max showed consistent elevation in the entire patient population when compared to baseline, while bioprosthetic TV echocardiographic parameters were relatively unchanged throughout. Post-operative warfarin therapy did not affect the rate of PV degeneration, and no major bleeding was recorded during or after post-operative anticoagulation therapy.

Conclusion

Bioprosthetic valve degeneration is common in CnHD. Monitoring with echocardiographic studies every 3 months, focusing on PV velocities, could identify patients with occult disease that very likely promotes valve degeneration. Novel neuroendocrine tumor therapies may have a beneficial impact on valve degeneration.

Race and Gender Disparity in the Surgical Management of Hepatocellular Cancer: Analysis of the Surveillance, Epidemiology, and End Results (SEER) Program Registry

BACKGROUND

The existence of race and gender disparity has been described in numerous areas of medicine. The management of hepatocellular cancer is no different, but in no other area of medicine, is the treatment algorithm more complicated by local, regional, and national health care distribution policy.

METHODS

Multivariate logistic regression and Cox-regression were utilized to analyze the treatment of patients with hepatocellular cancer registered in SEER between 1999 and 2013 to determine the incidence and effects of racial and gender disparity. Odd ratios (OR) are relative to Caucasian males, SEER region, and tumor characteristics.

RESULTS

The analysis of 57,449 patients identified the minority were female (25.31%) and African-American (16.26%). All tumor interventions were protective (p < 0.001) with respect to survival. The mean survival for all registered patients was 13.01 months with conditional analysis, confirming that African-American men were less likely to undergo ablation, resection, or transplantation (p < 0.001). Women were more likely to undergo resection (p < 0.001). African-American women had an equivalent OR for resection but had a significantly lower transplant rate (p < 0.001).

CONCLUSIONS

Utilizing SEER data as a surrogate for patient navigation in the treatment of hepatocellular cancer, our study identified not only race but gender bias with African-American women suffering the greatest. This is underscored by the lack of navigation of African-Americans to any therapy and a significant bias to navigate female patients to resection potentially limiting subsequent access to definitive therapy namely transplantation.

Regional variations in medical trainee diet and nutrition counseling competencies: Machine learning-augmented propensity score analysis of a prospective multi-site cohort study

BACKGROUND

Medical professionals and students are inadequately trained to respond to rising global obesity and nutrition-related chronic disease epidemics, primarily focusing on cardiovascular disease. Yet, there are no multi-site studies testing evidence-based nutrition education for medical students in preventive cardiology, let alone establishing student dietary and competency patterns.

METHODS

Cooking for Health Optimization with Patients (CHOP; NIH NCT03443635) was the first multi-national cohort study using hands-on cooking and nutrition education as preventive cardiology, monitoring and improving student diets and competencies in patient nutrition education. Propensity-score adjusted multivariable regression was augmented by 43 supervised machine learning algorithms to assess students outcomes from UT Health versus the remaining study sites.

RESULTS

3,248 medical trainees from 20 medical centers and colleges met study criteria from 1 August 2012 to 31 December 2017 with 60 (1.49%) being from UTHealth. Compared to the other study sites, trainees from UTHealth were more likely to consume vegetables daily (OR 1.82, 95%CI 1.04-3.17, p=0.035), strongly agree that nutrition assessment should be routine clinical practice (OR 2.43, 95%CI 1.45-4.05, p=0.001), and that providers can improve patients' health with nutrition education (OR 1.73, 95%CI 1.03-2.91, p=0.038). UTHealth trainees were more likely to have mastered 12 of the 25 competency topics, with the top three being moderate alcohol intake (OR 1.74, 95%CI 0.97-3.11, p=0.062), dietary fats (OR 1.26, 95%CI 0.57-2.80, p=0.568), and calories (OR 1.26, 95%CI 0.70-2.28, p=0.446).

CONCLUSION

This machine learning-augmented causal inference analysis provides the first results that compare medical students nationally in their diets and competencies in nutrition education, highlighting the results from UTHealth. Additional studies are required to determine which factors in the hands-on cooking and nutrition curriculum for UTHealth and other sites produce optimal student - and, eventually, preventive cardiology - outcomes when they educate patients in those classes.

Abstract W P225: The Relationship between Leukocytosis and Time to Neurodeterioration

Background: Previous research has illustrated how leukocytosis after acute ischemic stoke (AIS) is related to poor functional outcome. A main predictor of poor functional outcome is neurodeterioration (ND). We sought to explore the relationship between leukocytosis and time to ND to identify a risk factor for a process that predicts poor functional outcome.

Methods: Patients admitted to our stroke center (07/08-06/12) were retrospectively assessed. Leukocytosis was defined as WBC >11,000, ND was characterized as ≥ 2 point increase in NIHSS scale and poor functional outcome was classified as modified Rankin Scale (mRS) of 3-6. Patients were grouped into 2 categories: (1) the leukocytosis group- those who developed leukocytosis ≥24 hours after admission and those who presented with leukocytosis and remained at 24 hours and, (2) the non-leukocytosis group- those that did not have leukocytosis and those where the leukocytosis resolved within 24 hours of admission.

Results: A cohort of AIS patients (N=476) with median age 64 years, 43% female and 69% Black were assessed. Of the patients with ND (27%), median time to ND was 43 hours. In the leukocytosis group (N=84), 42 (50.6%) of them developed ND. In the non-leukocytosis group (N=312), 75 (24.5%) developed ND. Leukocytosis within 24 hours of admission is predictive of earlier time to ND (p<0.0001; Figure 1). Adjusting for age, stroke severity, glucose, tPA and infection, the leukocytosis group had a 2 times greater risk for developing ND (HR 2.49, 95%CI 1.61-3.84, p<0.0001).

Conclusion: Having leukocytosis persist from admission to 24 hours or developing leukocytosis within 24 hours of admission is a significant predictor of early ND, which often results in poor functional outcome. Identifying such a predictor can enable physicians to identify those at risk for ND and subsequent poor functional outcomes. Future studies are needed to identify if interventions targeting leukocytosis may improve outcome after stroke.

Abstract 3790: The TIA Admission Score - A Tool to Determine Observation Versus Inpatient Admission Status for TIA

BACKGROUND: Centers for Medicare and Medicaid Services has criteria for admission to observation vs. inpatient status, one of which is expected discharge within 24 hours. Validated scores predicting the likelihood of stroke after TIA are useful in supporting admission, but do not assist with assigning admission status. We developed a scoring system that predicts which patients presenting with TIA would have a high probability of LOS >23 hours.

METHODS: Patients presenting to our stroke center from 7/08-12/10 with a diagnosis of TIA were identified from a prospective stroke registry containing demographic and clinical characteristics. A scoring system was created to estimate the probability of a LOS >23hrs based on patient demographics, past medical history, and current medication. Potential predictors of LOS >23hrs with sensitivity ≥65% or (area under the curve) AUC ≥0.6 were evaluated to determine if they demonstrated significant, independent associations with LOS >23hrs using logistic regression, adjusting for weekend admission. Sensitivity and specificity were used to evaluate the score’s ability to predict observation status (LOS ≤23hrs, score ≤2), as well as inpatient status (LOS >23hrs, score ≥4).

RESULTS: Out of 223 patients with TIA (52% F, 58% AA, median age 62) 110 (49%) had a hospital stay of >23 hours. Patients with LOS >23hrs were older (p=.036), more frequently had a history of coronary artery disease (CAD) (p<.001) and congestive heart failure (p=.059), and more frequently reported taking blood pressure (BP) medications (p=.008). No significant differences were observed in the two groups with regards to the remaining demographic and clinical variables. The TIA admission score ranges from 0-6, consisting of age >70yrs (2 points), presence of CAD (2 points), current use of BP medications (1 point), and being African American (1 point). As shown in Figure 1 , 85% of patients with a score of 6 had a LOS>23hrs, as compared to 50% in patients with a score of 3, and 29% of patients with a score of 1. A score of ≤2 showed a sensitivity of 68% (specificity 79%) for identifying observation status, whereas a score of ≥4 showed a sensitivity of 79% (specificity 58%) for identifying inpatient status.

CONCLUSIONS: In our population of TIA patients, clinical characteristics available on presentation identified admission to observation and inpatient status with acceptable sensitivities and specificities. Validation is required in other populations. If validated, this score could assist providers in determining whether TIA patients should be admitted under observation or inpatient status.