Appropriateness of implantable cardioverter-defibrillator device implants in the United States

BACKGROUND

The appropriate use criteria (AUCs) are a diverse group of indications aimed to better evaluate the benefits of implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy.

OBJECTIVE

The purpose of this study was to quantify the proportion of ICD and cardiac resynchronization therapy with defibrillator (CRT-D) implants as appropriate, may be appropriate (MA), or rarely appropriate (RA) on the basis of the AUC guidelines.

METHODS

This is a multicenter retrospective study of patients within the National Cardiovascular Data Registry undergoing ICD implantation between April 2018 and March 2019 at >1500 US hospitals. The appropriateness of ICD implants was adjudicated using the AUC.

RESULTS

Of 309,318 ICDs, 241,438 were primary prevention implants (78.1%) and 67,880 secondary prevention implants (21.9%); 243,532 (79%) were mappable to the AUC. For primary prevention, 185,431 ICDs (96.4%) were appropriate, 5660 (2.9%) MA, and 1205 (0.6%) RA. For secondary prevention, 47,498 ICDs (92.7%) were appropriate, 2581 (5%) MA, and 1157 (2.3%) RA. A significant number of RA devices were implanted in patients with New York Heart Association class IV heart failure who were ineligible for advanced therapies (53.9%) and those with myocardial infarction within 40 days (18.1%). The appropriateness of the pacing lead was more variable, with 48,470 dual-chamber ICD implants (62%) being classified as appropriate, 29,209 (37.4%) MA, and 448 (0.6%) RA. Among CRT-D implants, 63,848 (82.2%) were appropriate, 9900 (12.7%) MA, and 3940 (5.1%) RA for left ventricular pacing. A total of 99,754 implants were deemed appropriate but excluded from Centers for Medicare & Medicaid Services National Coverage Determination. More than 92% of hospitals had an RA implant rate of <4%.

CONCLUSION

In this large national registry, 95% of mappable ICD and CRT-D implants were considered appropriate, with <2% of RA implants. Nearly 100,000 appropriate implants are excluded by Centers for Medicare & Medicaid Services National Coverage Determination.

Systematic methodological review of health state values in glaucoma cost-utility analyses

IMPORTANCE

Describing the characteristics and sources of health state utility values and reporting practice in the literature of cost-utility analyses facilitates an understanding of the level of the transparency, validity, and generalizability of cost-utility analyses. Improving the quality of reporting will support investigators in describing the incremental value of emerging glaucoma interventions.

OBJECTIVE

To describe the state of practice among published glaucoma cost-utility analysis studies, focusing on valuation of health and the quality of reporting.

EVIDENCE REVIEW

We searched several databases including Medline, CINHAL, Embase, Web of Science, Scopus, Biosis previews, the Health Economic Evaluations Database, and the NHS Economic Evaluation Database (NHS EED). We included full-text, English, published cost-utility analyses of glaucoma interventions with quality-adjusted life years (QALYs) as the primary outcome measure to calculate incremental cost-utility ratios. Excluded studies were non-English language, reviews, editorials, protocols, or other types of economic studies (cost-benefit, cost-minimization, cost-effectiveness). Study characteristics, operational definitions of glaucoma health states and health state utilities were extracted. The original source of the health utility was reviewed to determine the scale of measurement and the source of preference weighting. Items from the Systematic Review of Utilities for Cost-Effectiveness (SpRUCE checklist) were used to assess the reporting and quality of health utilities in glaucoma CUA.

FINDINGS

43 CUAs were included, with 11 unique sources of health utilities. A wide range of health utilities for the same Hodapp-Parrish-Anderson glaucoma health states were reported; ocular hypertension (0.84-0.95), mild (0.68-0.94), moderate (0.57-0.92), advanced (0.58-0.88), severe/blind (0.46-0.76), and bilateral blindness (0.26-0.5). Most studies reported the basis for using health utilities (34, 79%) and any assumptions or adjustments applied to the health utilities (22, 51%). Few studies reported a framework for assessing the relevance of health utilities to a decision context (8, 19%). Even fewer (3, 7%) applied a systematic search strategy to identify health utilities and used a structured assessment of quality for inclusion. Overall, reporting has not improved over time.

CONCLUSIONS AND RELEVANCE

This review describes that few CUAs describe important rationale for using health state utility values. Including additional details on the search, appraisal, selection, and inclusion process of health utility values improves transparency, generalizability and supports the assessment of the validity of study conclusions. Future investigations should aim to use health utilities on the same scale of measurement across health states and consider the source and relevance to the decision context/purpose of conducting that cost-utility study.

Hospital Variation in Epinephrine Administration Before Defibrillation for Cardiac Arrest Due to Shockable Rhythm

OBJECTIVES

Contrary to advanced cardiac life support guidelines that recommend immediate defibrillation for shockable in-hospital cardiac arrest (IHCA), epinephrine administration before first defibrillation is common and associated with lower survival at a "patient-level." Whether this practice varies across hospitals and its association with "hospital-level" IHCA survival remains unknown. The purpose of this study was to determine hospital variation in rates of epinephrine administration before defibrillation for shockable IHCA and its association with IHCA survival.

DESIGN

Observational cohort study.

SETTING

Five hundred thirteen hospitals participating in the Get With The Guidelines Resuscitation Registry.

PATIENTS

A total of 37,668 adult patients with IHCA due to an initial shockable rhythm from 2000 to 2019.

INTERVENTIONS

Epinephrine before first defibrillation.

MEASUREMENTS AND MAIN RESULTS

Using multivariable hierarchical regression, we examined hospital variation in epinephrine administration before first defibrillation and its association with hospital-level rates of risk-adjusted survival. The median hospital rate of epinephrine administration before defibrillation was 18.8%, with large variation across sites (range, 0-68.8%; median odds ratio: 1.54; 95% CI, 1.47-1.61). Major teaching status and annual IHCA volume were associated with hospital rate of epinephrine administration before defibrillation. Compared with hospitals with the lowest rate of epinephrine administration before defibrillation (Q1), there was a stepwise decline in risk-adjusted survival at hospitals with higher rates of epinephrine administration before defibrillation (Q1: 44.3%, Q2: 43.4%; Q3: 41.9%; Q4: 40.3%; p for trend < 0.001).

CONCLUSIONS

Administration of epinephrine before defibrillation in shockable IHCA is common and varies markedly across U.S. hospitals. Hospital rates of epinephrine administration before defibrillation were associated with a significant stepwise decrease in hospital rates of risk-adjusted survival. Efforts to prioritize immediate defibrillation for patients with shockable IHCA and avoid early epinephrine administration are urgently needed.

Early Rehabilitation in Critically ill Children: A Two Center Implementation Study

OBJECTIVES

To implement an early rehabilitation bundle in two Canadian PICUs.

DESIGN AND SETTING

Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2).

PATIENTS

All children under 18 years old admitted to the PICU were eligible for the intervention.

INTERVENTIONS

A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement.

CONCLUSIONS

A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Survey of resuscitation practices at emergency medical service agencies in the U.S

Background

Survival for out-of-hospital cardiac arrest (OHCA) varies across emergency medical service (EMS) agencies. Yet, little is known about resuscitation response and quality improvement activities at EMS agencies. We describe herein a novel survey to EMS agencies in a U.S. registry for OHCA.

Methods

Using data from the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 577 EMS agencies with ≥10 OHCA cases annually between 2015 and 2019 that remained active in CARES. We administered a survey to EMS directors regarding agency characteristics, cardiac arrest response, relationships with first responders and dispatchers, quality improvement activities and perceived barriers in the community.

Results

Of eligible EMS agencies, 470 (81.5%) completed the survey. The high completion rate was likely due to frequent personalized emails and phone calls, liaising with CARES state coordinators to encourage survey response, and multiple periodic drawings of an automated external defibrillator during the survey period for participating EMS agencies. The survey examined rates of resuscitation training modalities; use of resuscitation equipment and devices in the field; frequency of simulation; non-EMS stakeholder response to OHCA (dispatchers, fire, police); quality improvement; and community factors affecting bystander response to OHCA.

Conclusions

In this study design paper on the RED-CASO survey, we provide summary data on EMS agency characteristics in the U.S. Upon linkage to CARES patient-level data, this survey will provide critical insights into 'best practices' at EMS agencies with the highest OHCA survival rates as well as provide insights into current disparities in outcomes.

Trauma - It is a party, but is everyone invited? A single center retrospective analysis of trauma patients at risk for early discharge after transfer

BACKGROUND

Transferred trauma patients frequently are discharged after short stays without undergoing treatments. Strategies to decrease unnecessary transfers are needed.

METHODS

We conducted a retrospective analysis of patients transferred to our level I center from 2019 to 2021. We identified patients discharged within 24 h without interventions and compared demographic, activation, injury, and mechanism of injury characteristics with patients requiring more care. A risk score was developed from these factors.

RESULTS

Of 2424 patients transferred, 463(19%) were discharged within 24 h. In an integer score, age (1 pt), Injury Severity Score (<6 = 5 pts, 7-9 = 2 pts), recreational mechanism (3 pts), no hypertension (1 pt), no diabetes (2 pts), no dementia (3 pts), chest (1 pt), external (4 pts), face (5 pts) and Head/neck trauma (2 pts) were associated with early discharge. The score stratified risk of early discharge from 4.8% (score <7) to 67% (score >15).

CONCLUSION

When prospectively validated the risk score may identify patients who can be managed without transfer.

A multimodal antimicrobial stewardship intervention to improve antibiotic prescribing in patients with COVID-19

This study assessed outcomes prior to and after electronic medical record-based clinical decision support implementation combined with prospective audit in patients with COVID-19. This multimodal stewardship intervention was associated with a decrease in antibiotic exposure for patients with COVID-19 (44.4% vs 61.8%, p = 0.002) within the first 7 days of hospitalization.

Implications of a Race Term in GFR Estimates Used to Predict AKI After Coronary Intervention

BACKGROUND

The prediction of mortality, bleeding, and acute kidney injury (AKI) after percutaneous coronary intervention (PCI) traditionally relied on race-based estimates of the glomerular filtration rate (GFR). Recently, race agnostic equations were developed to advance equity.

OBJECTIVES

The authors aimed to compare the accuracy and implications of various GFR equations when used to predict AKI after PCI.

METHODS

Using the National Cardiovascular Data Registry (NCDR) CathPCI data set, we identified patients undergoing PCI in 2020 and calculated their AKI risk using the 2014 NCDR AKI risk model. We created 4 AKI models per patient for each estimate of baseline renal function: the traditional GFR equation with a race term, 2 GFR equations without a race term, and serum creatinine alone. We then compared each model's performance predicting AKI.

RESULTS

Among 455,806 PCI encounters, the median age was 67 years, 32.2% were women, and 8.5% were Black. In Black patients, risk models without a race term were better calibrated than models incorporating an equation with a race term (intercept: -0.01 vs 0.15). Race-agnostic models reclassified 6% of Black patients into higher-risk categories, potentially prompting appropriate mitigation efforts. However, even with a race-agnostic model, AKI occurred in Black patients 18% more often than expected, which was not explained by captured patient or procedural characteristics.

CONCLUSIONS

Incorporating a GFR estimate without a Black race term into the NCDR AKI risk prediction model yielded more accurate prediction of AKI risk for Black patients, which has important implications for reducing disparities and benchmarking.

Contemporary Methods for Predicting Acute Kidney Injury After Coronary Intervention

BACKGROUND

Acute kidney injury (AKI) is the most common complication after percutaneous coronary intervention (PCI). Accurately estimating patients' risks not only creates a means of benchmarking performance but can also be used prospectively to inform practice.

OBJECTIVES

The authors sought to update the 2014 National Cardiovascular Data Registry (NCDR) AKI risk model to provide contemporary estimates of AKI risk after PCI to further improve care.

METHODS

Using the NCDR CathPCI Registry, we identified all 2020 PCIs, excluding those on dialysis or lacking postprocedural creatinine. The cohort was randomly split into a 70% derivation cohort and a 30% validation cohort, and logistic regression models were built to predict AKI (an absolute increase of 0.3 mg/dL in creatinine or a 50% increase from preprocedure baseline) and AKI requiring dialysis. Bedside risk scores were created to facilitate prospective use in clinical care, along with threshold contrast doses to reduce AKI. We tested model calibration and discrimination in the validation cohort.

RESULTS

Among 455,806 PCI procedures, the median age was 67 years (IQR: 58.0-75.0 years), 68.8% were men, and 86.8% were White. The incidence of AKI and new dialysis was 7.2% and 0.7%, respectively. Baseline renal function and variables associated with clinical instability were the strongest predictors of AKI. The final AKI model included 13 variables, with a C-statistic of 0.798 and excellent calibration (intercept = -0.03 and slope = 0.97) in the validation cohort.

CONCLUSIONS

The updated NCDR AKI risk model further refines AKI prediction after PCI, facilitating enhanced clinical care, benchmarking, and quality improvement.

Comparison of Out-of-Hospital Cardiac Arrest Outcomes Between Asian and White Individuals in the United States

Background Disparities in bystander cardiopulmonary resuscitation (CPR) and survival have been reported for Black and Hispanic individuals with out-of-hospital cardiac arrest (OHCA). Whether Asian individuals have lower rates of bystander CPR and survival for OHCA, as compared with White individuals, remains unknown. Methods and Results Within the US-based CARES (Cardiac Arrest Registry to Enhance Survival), we identified 278 989 OHCAs in Asian and White individuals during 2013 to 2021. Using hierarchical Poisson logistic regression with emergency medical service agency modeled as a random effect and patient and OHCA characteristics as fixed effects, we compared rates of bystander CPR, survival to discharge, and favorable neurological survival between Asian and White individuals with OHCA. Overall, 14 835 (5.3%) OHCAs occurred in Asian individuals. Compared with White individuals with OHCA, Asian individuals were older (67.0±17.6 versus 62.8±16.9 years) and were less likely to have drug overdose as the cause of OHCA (1.3% versus 6.6%) and a shockable arrest rhythm (19.2% versus 22.4%). Layperson bystander CPR rates were similar between Asian and White individuals (42.6% versus 42.1%; adjusted relative risk for Asian individuals, 0.99 [95% CI, 0.97-1.02]; P=0.69). However, rates of survival to discharge were lower in Asian individuals with OHCA (8.2% versus 10.3%; adjusted relative risk 0.92 [0.86-0.98] P=0.006). Similarly, the rate of favorable neurological survival was lower for Asian individuals (6.5% versus 8.7%; adjusted relative risk, 0.85 [0.79-0.91]; P<0.001). Conclusions Despite similar rates of bystander CPR, Asian individuals with OHCA have lower survival rates than White individuals with OHCA. The reasons for the lower survival rate deserve further study to determine whether there are disparities in resuscitation care between Asian and White individuals with OHCA.

Establishing a Virtual Home Assessment Program: from Concept to Implementation as a Result of the COVID-19 Pandemic

PURPOSE OF REVIEW

Environmental home assessments have traditionally been performed in-person at the homes of Children's Mercy Kansas City patients. The COVID-19 pandemic brought many challenges to the way patients interact with their healthcare providers, including home visiting programs. Reaching out to patients with high-risk asthma and immunocompromised health was still needed, despite the pandemic. This project's purpose was to develop a virtual (telemedicine) healthy home assessment protocol that would continue to meet patients' needs during the isolation resulting from the pandemic.

RECENT FINDINGS

This is a newly developing approach to performing home environmental assessments with limited published research. Research on the effective use of telemedicine as an alternative to in-person clinic visits has shown that for some health conditions telemedicine represents a useful technique to engage with patients and caregivers. For some conditions, like pediatric asthma, it provides a similar level of efficacy in disease management while providing a more efficient form of interaction. This article describes the development and delivery process, timelines of caregiver interaction, and guidelines for performing virtual home assessments. It summarizes the challenges and benefits of using a virtual process for delivering home assessment services for asthma and allergy patients. Overall, caregivers indicated they found the use of virtual technology had significant benefits for them including their personal comfort and the time efficiency gained by using virtual visits to interact with Healthy Homes Program staff.

Outcomes With Peripheral Venoarterial Extracorporeal Membrane Oxygenation for Suspected Acute Myocarditis: 10-Year Experience From the Extracorporeal Life Support Organization Registry

BACKGROUND

Acute myocarditis can result in severe hemodynamic compromise requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO). Outcomes and factors associated with mortality among myocarditis patients are not well described in the modern ECMO era.

METHODS

We queried the Extracorporeal Life Support Organization registry from 2011 to 2020 for adults with suspected acute myocarditis undergoing peripheral VA-ECMO support. The primary outcome was in-hospital mortality and was compared to all-comers receiving VA-ECMO in the registry over the same period. Secondary outcomes were rates of bridging to advanced therapies and ECMO complications. We used multivariable logistic regression to examine factors associated with in-hospital mortality.

RESULTS

Among 850 patients with suspected acute myocarditis receiving peripheral VA-ECMO, the mean age was 41 years, 52% were men, 39% Asian race, and 14.8% underwent extracorporeal cardiopulmonary resuscitation. During the study period, in-hospital mortality steadily declined and was 58.3% for all all-comers receiving VA-ECMO compared with 34.9% for patients with myocarditis (P<0.001). After multivariable modeling, risk factors for mortality were earlier year of support, older age, higher weight, Asian race, need for extracorporeal cardiopulmonary resuscitation, sepsis, and lower mean arterial pressure and pH prior to ECMO initiation. ECMO complications including bleeding, limb ischemia, infections and ischemic stroke were more common among nonsurvivors and significantly declined during the study period.

CONCLUSIONS

Compared with all-comers supported with VA-ECMO, in-hospital mortality for patients with acute myocarditis is significantly lower, with nearly two-thirds of patients surviving to discharge. Major modifiable risk factors for mortality were ongoing cardiopulmonary resuscitation requiring ECMO and markers of illness severity prior to ECMO.

Subjective Assessment Underestimates Fraility in Patients With Heart Failure Referred for Advanced Therapies

Assessment of frailty is key for evaluation for advanced therapies (ATs). Most programs use a subjective provider assessment (SPA) or "eye-ball" test; however, objective measures exist. The modified five-item Fried Frailty Index (mFFI) is a validated tool to assess frailty. We compared SPA to mFFI testing in patients referred for AT. We also compared levels of macrophage migration inhibitory factor (MIF), an inflammatory biomarker associated with worse outcomes in heart failure, between frail and not frail subjects. Seventy-eight patients referred for evaluation for AT underwent both SPA and mFFI testing. Three cardiac surgeons independently assessed patients for frailty (SPA). SPA significantly underestimated frailty compared with mFFI testing and correlation between SPA and mFFI was not strong (κ = 0.02-0.14). Providers were correct 84% of the time designating a subject as frail, but only 40% of the time designating as not frail. Agreement between all three providers was robust (76%), which was primarily driven by designation as not frail. There was no significant difference in plasma MIF levels between frail and not frail subjects (47.6 ± 25.2 vs . 45.2 ± 18.9 ng/ml; p = 0.6). Clinicians significantly underestimate frailty but are usually correct when designating a patient as frail.

Resurrecting Multiattribute Utility Function: Developing a Value Set for Health Utility for Glaucoma

OBJECTIVES

This study aimed to develop a scoring function to calculate health utilities for health states described by the Health Utility for Glaucoma (HUG-5) based on the preferences of the general population in the United States.

METHODS

Preferences for HUG-5 health states were elicited using the standard gamble and visual analog scale through an online survey. Quota-based sampling was used to recruit a representative sample of the US general population in terms of age, sex, and race. A multiple attribute disutility function (MADUF) approach was adopted to derive scoring for the HUG-5. Model fit was assessed using mean absolute error associated with 5 HUG-5 marker health states that describe mild/moderate and severe glaucoma.

RESULTS

Of 634 respondents completing the tasks, 416 were included in the estimation of the MADUF; 260 respondents (63%) considered worst possible HUG-5 health state better than death. The preferred scoring function generates the utilities ranging from 0.05 (worst HUG-5 health state) to 1 (best HUG-5 health state). The correlation between mean elicited and estimated values for marker states was strong (R² = 0.97) with mean absolute error = 0.11.

CONCLUSIONS

The MADUF for HUG-5 is used to measure health utilities on the scale of perfect health and death, which can be used to estimate quality-adjusted life-years for economic evaluations of glaucoma interventions.

A novel image-based method for simultaneous counting of Lactobacillus and Saccharomyces in mixed culture fermentation

Mixed microorganism cultures are prevalent in the food industry. From sour beer to sourdough bread, mixed culture popularity has been growing steadily. A variety of microbiological mixtures have been used in these unique fermenting processes to create distinctive flavor profiles and potential health benefits. Although mixed cultures may seem ubiquitous, they are typically not well characterized, which may be due to the lack of user-friendly and simple measurement tools. Image-based cytometry systems have been employed to count bacteria or yeast cells directly and rapidly in plastic chambers, as opposed to traditional cell counting methods that can take days to grow and count. In this work, we aim to develop a novel image cytometry method to distinguish and enumerate mixed cultures of yeast and bacteria in beer products. We demonstrate that the proposed image cytometry method can be used to rapidly distinguish and simultaneously count the bacteria and yeast cells mixed cultures. The Cellometer X2 from Nexcelom was used to automate the counting of Lactobacillus plantarum and Saccharomyces cerevisiae in a mixed culture using fluorescent dyes and size exclusion image analysis algorithm. The proposed image cytometry method was tested with a series of experiments. (1) Yeast and bacteria monoculture titration, (2) mixed culture with various ratios, and (3) monitoring a Berliner Weisse mixed culture fermentation. All experiments were validated by comparing directly to manual counting of yeast and bacteria colony formation on agar plates. The two counting methods were highly comparable with ANOVA analysis showing p-value > 0.05 for all trials. The image cytometry method was the most accurate for yeast concentrations between 105-107 cells/mL and 106-108 cells/mL for lactic acid bacteria. Overall, the novel image cytometry method was able to distinguish and count mixed cultures consistently and accurately, which may provide better characterization and assessment of mixed culture brewing applications that may produce more consistent and higher quality products.

PRECISE-DAPT and ARC-HBR Predict in-Hospital Outcomes in Patients Who Underwent Percutaneous Coronary Intervention

Bleeding events result in morbidity and mortality in patients who underwent percutaneous coronary intervention (PCI). There are limited data on the predicting bleeding complications in patients who underwent stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) and Academic Research Consortium for High Bleeding Risk (ARC-HBR) scores' ability to predict in-hospital outcomes in patients who underwent PCI. Consecutive patients who underwent PCI at tertiary centers from January 2016 to March 2018 were identified and the bleeding risk scores were calculated. The primary end point was the National Cardiovascular Data Registry-defined in-hospital bleeding stratified by low versus high predicted bleeding risk. The major and net adverse cardiovascular events were also examined. The discriminatory ability of the risk models was determined using receiver operating characteristic curves. Among 3,659 patients studied, the in-hospital major bleeding was 3.3% (n = 121). The patients characterized as high bleeding risk by either criterion had significantly higher bleeding rates than those meeting the low-risk criteria (ARC-HBR 5.4% vs 3.3%, p <0.001; PRECISE-DAPT 5.8% vs 2.4%, p <0.001), and higher major adverse cardiovascular events and net adverse clinical events. These risk estimates showed moderate and similar predictive ability (ARC-HBR high-risk area under the receiver operating characteristic curve [AUC] 0.62, PRECISE-DAPT ≥25 AUC 0.61, p = 0.49), with no incremental benefit to adding the estimates (AUC 0.60). The subgroup analysis revealed that women had higher bleeding rates than men (5.53% vs 2.39%, p <0.001); however, the predictive ability of the criteria were similar in women and men. The patients identified as having a high bleeding risk by the PRECISE-DAPT and the ARC-HBR criteria before PCI are at high risk for in-hospital bleeding and adverse outcomes independent of gender. The 2 scores have moderate predictive ability for bleeds. Further study is needed to determine strategies to reduce risk in this population.

Site-level variability in the processes of care and outcomes over time among patients with COVID-19 and myocardial injury: Insights from the American Heart Association's COVID-19 Cardiovascular Disease Registry

Background

Elevated cardiac troponin (cTn) levels in patients with COVID-19 has been associated with worse outcomes. Guidelines on best practices of those patients remain uncertain.

Methods

We included patients with COVID-19 and cTn above the assay-specific upper limit of normal (ULN) enrolled in the American Heart Association's COVID-19 registry between March 2020-January 2021. Site-level variability in invasive coronary angiography, LVEF assessment, ICU utilization, and inpatient mortality were determined by calculating adjusted median odds ratio (MOR) using hierarchical logistic regression models. Temporal trends were assessed with Cochran-Armitage trend test.

Results

Among 32,636 patients, we included 6234 (19.4 %) with cTn above ULN (age 68.7 ± 16.0 years, 56.5 % male, 51.5 % Caucasian), of whom 1365 (21.6 %) had ≥5-fold elevations. Across 55 sites, the median rate of invasive coronary angiography was 0.1 % with adjusted MOR 1.5(1.0,2.3), median LVEF assessment was 25.5 %, MOR 3.0(2.2,3.9), ICU utilization was 41.7 %, MOR 2.2(1.8,2.6), and mortality was 20.9 %, MOR 1.7(1.5,2.0). Over time, we noted a significant increase in invasive coronary angiography (p-trend = 0.001), and LVEF assessment (p-trend<0.001), and reduction in mortality (p-trend<0.001), without significant change in ICU admissions (p-trend = 0.08). Similar variability and temporal trends were seen among patients with ≥5-fold cTn elevation.

Conclusions

The use of invasive coronary angiography among patients with COVID-19 and myocardial injury was very low during the early pandemic. We found moderate institutional variability in processes of care with an uptrend in invasive catheterization and LVEF assessment, and downtrend in mortality. Comparative effectiveness studies are needed to examine whether variability in care is associated with differences in outcomes.

Impact of withdrawal time on adenoma detection rate: results from a prospective multicenter trial

BACKGROUND AND AIMS

Performing a high-quality colonoscopy is critical for optimizing the adenoma detection rate (ADR). Colonoscopy withdrawal time (a surrogate measure) of ≥6 minutes is recommended; however, a threshold of a high-quality withdrawal and its impact on ADR are not known.

METHODS

We examined withdrawal time (excluding polyp resection and bowel cleaning time) of subjects undergoing screening and/or surveillance colonoscopy in a prospective, multicenter, randomized controlled trial. We examined the relationship of withdrawal time in 1-minute increments on ADR and reported odds ratio (OR) with 95% confidence intervals. Linear regression analysis was performed to assess the maximal inspection time threshold that impacts the ADR.

RESULTS

A total of 1142 subjects (age, 62.3 ± 8.9 years; 80.5% men) underwent screening (45.9%) or surveillance (53.6%) colonoscopy. The screening group had a median withdrawal time of 9.0 minutes (interquartile range [IQR], 3.3) with an ADR of 49.6%, whereas the surveillance group had a median withdrawal time of 9.3 minutes (IQR, 4.3) with an ADR of 63.9%. ADR correspondingly increased for a withdrawal time of 6 minutes to 13 minutes, beyond which ADR did not increase (50.4% vs 76.6%, P < .01). For every 1-minute increase in withdrawal time, there was 6% higher odds of detecting an additional subject with an adenoma (OR, 1.06; 95% confidence interval, 1.02-1.10; P = .004).

CONCLUSIONS

Results from this multicenter, randomized controlled trial underscore the importance of a high-quality examination and efforts required to achieve this with an incremental yield in ADR based on withdrawal time. (Clinical trial registration number: NCT03952611.).

Using exterior housing conditions to predict elevated pediatric blood lead levels

Housing-based lead paint dust is the most common source of lead exposure for US-born children. Although year of housing construction is a critical indicator of the lead hazard to US children, not all housing of the same age poses the same risk to children. Additional information about housing condition is required to differentiate the housing-based lead risk at the parcel level. This study aimed to identify and assess a method for gathering and using observations of exterior housing conditions to identify active housing-based lead hazards at the parcel level. We used a dataset of pediatric blood lead observations (sample years 2000-2013, ages 6-72 months, n = 6,589) to assess associations between observations of exterior housing conditions and housing-based lead risk. We used graphical and Lasso regression methods to estimate the likelihood of an elevated blood lead observation (≥3.5 μg/dL). Our methods estimate a monotonic increase in the likelihood of an elevated blood lead observation as housing conditions deteriorate with the largest changes associated with homes in the greatest disrepair. Additionally we estimate that age of home construction works in consort with housing conditions to amplify risks among those houses built before 1952. Our analysis indicates that a survey of external housing conditions can be used in combination with age of housing in the identification process, at the parcel level, of homes that pose a housing-based lead hazard to children.

Preoperative Rehabilitation Is Feasible in the Weeks Prior to Surgery and Significantly Improves Functional Performance

BACKGROUND

Frailty is a multidimensional state of increased vulnerability. Frail patients are at increased risk for poor surgical outcomes. Prior research demonstrates that rehabilitation strategies deployed after surgery improve outcomes by building strength.

OBJECTIVES

Examine the feasibility and impact of a novel, multi-faceted prehabilitation intervention for frail patients before surgery.

DESIGN

Single arm clinical trial.

SETTING

Veterans Affairs hospital.

PARTICIPANTS

Patients preparing for major abdominal, urological, thoracic, or cardiac surgery with frailty identified as a Risk Analysis Index≥30.

INTERVENTION

Prehabilitation started in a supervised setting to establish safety and then transitioned to home-based exercise with weekly telephone coaching by exercise physiologists. Prehabilitation included (a)strength and coordination training; (b)respiratory muscle training (IMT); (c)aerobic conditioning; and (d)nutritional coaching and supplementation. Prehabilitation length was tailored to the 4-6 week time lag typically preceding each participant's normally scheduled surgery.

MEASUREMENTS

Functional performance and patient surveys were assessed at baseline, every other week during prehabilitation, and then 30 and 90 days after surgery. Within-person changes were estimated using linear mixed models.

RESULTS

43 patients completed baseline assessments; 36(84%) completed a median 5(range 3-10) weeks of prehabilitation before surgery; 32(74%) were retained through 90-day follow-up. Baseline function was relatively low. Exercise logs show participants completed 94% of supervised exercise, 78% of prescribed IMT and 74% of home-based exercise. Between baseline and day of surgery, timed-up-and-go decreased 2.3 seconds, gait speed increased 0.1 meters/second, six-minute walk test increased 41.7 meters, and the time to complete 5 chair rises decreased 1.6 seconds(all P≤0.007). Maximum and mean inspiratory and expiratory pressures increased 4.5, 7.3, 14.1 and 13.5 centimeters of water, respectively(all P≤0.041).

CONCLUSIONS

Prehabilitation is feasible before major surgery and achieves clinically meaningful improvements in functional performance that may impact postoperative outcomes and recovery. These data support rationale for a larger trial powered to detect differences in postoperative outcomes.

Early impacts of the COVID-19 pandemic on children with pediatric rheumatic diseases

OBJECTIVES

The experiences of children with pediatric rheumatic diseases (PRD) during the initial phase of the COVID-19 pandemic have not been well-documented. We sought to determine the effects of the COVID-19 pandemic on protective behaviors, healthcare access, medication management, and education among an international cross-sectional parental survey of children with PRDs.

METHODS

The COVID-19 Global Rheumatology Alliance Patient Experience Survey was distributed online, and parents of children with parental-reported PRD, with or without COVID-19 infection, were eligible to enroll. Respondents described their child's demographics, adoptions of protective behaviors, healthcare access, changes to immunosuppression, and disruptions in schooling.

RESULTS

A total of 427 children were included in the analyses. The most common rheumatic disease was juvenile idiopathic arthritis (40.7%), and most children were taking conventional synthetic diseasemodifying antirheumatic drugs (DMARDs) (54.6%) and/or biologic DMARDs (51.8%). A diagnosis of COVID-19 was reported in five children (1.2%), none of whom required hospitalization. Seventeen children (4.0%) had stopped or delayed their drugs due to concern for immunosuppression, most commonly glucocorticoids. Almost all families adopted behaviors to protect their children from COVID-19, including quarantining, reported by 96.0% of participants. In addition, 98.3% of full-time students experienced disruptions in their education, including cancelations of classes and transitions to virtual classrooms.

CONCLUSION

Despite the low numbers of children with PRDs who developed COVID-19 in this cohort, most experienced significant disruptions in their daily lives, including quarantining and interruptions in their education. The drastic changes to these children's environments on their future mental and physical health and development remain unknown.

Templated microbiology comments with candiduria to enhance antimicrobial stewardship

OBJECTIVE

To evaluate the effect of templated microbiology reporting comments on antifungal utilization in patients with candiduria.

DESIGN

In this retrospective, quasi-experimental study, we evaluated a preimplementation cohort (June 2018-January 2019) compared with a postimplementation cohort (June 2019-January 2020).

SETTING

A multisite health system including 1 academic hospital and 4 community hospitals.

PATIENTS

Patients were aged ≥18 years, were hospitalized, and had candiduria documented at least once during their admission. The study included 156 patients in the preimplementation period and 141 patients in the postimplementation period.

METHODS

In June 2019, Saint Luke's Health System implemented the use of templated comments for urine cultures with Candida spp growth. When Candida is isolated, the following comment appears in the microbiology result section: "In the absence of symptoms, Candida is generally considered normal flora. No therapy indicated unless high risk (pregnant, neonate, or neutropenic) or undergoing urologic procedure. If Foley catheter present, remove or replace when able." The primary outcome was rate of antifungal prescribing.

RESULTS

Antifungal administration within 72 hours of a culture identifying a Candida spp occurred in 75 patients in the preimplementation group and 48 patients in the postimplementation group (48.1% vs 34.0%; P = .02). We did not detect a difference between groups in antifungal administration between 73 and 240 hours (1.3% vs 3.5%; P = .26), nor did we detect a difference in median antifungal duration (4 vs 3 days; P = .43).

CONCLUSION

Using a templated comment with urine cultures reduced antifungal prescription rates in hospitalized patients with candiduria. This strategy is a low-resource technique to improve antimicrobial stewardship.

Prolonged COVID-19 symptom duration in people with systemic autoimmune rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance Vaccine Survey

OBJECTIVE

We investigated prolonged COVID-19 symptom duration, defined as lasting 28 days or longer, among people with systemic autoimmune rheumatic diseases (SARDs).

METHODS

We analysed data from the COVID-19 Global Rheumatology Alliance Vaccine Survey (2 April 2021-15 October 2021) to identify people with SARDs reporting test-confirmed COVID-19. Participants reported COVID-19 severity and symptom duration, sociodemographics and clinical characteristics. We reported the proportion experiencing prolonged symptom duration and investigated associations with baseline characteristics using logistic regression.

RESULTS

We identified 441 respondents with SARDs and COVID-19 (mean age 48.2 years, 83.7% female, 39.5% rheumatoid arthritis). The median COVID-19 symptom duration was 15 days (IQR 7, 25). Overall, 107 (24.2%) respondents had prolonged symptom duration (≥28 days); 42/429 (9.8%) reported symptoms lasting ≥90 days. Factors associated with higher odds of prolonged symptom duration included: hospitalisation for COVID-19 vs not hospitalised and mild acute symptoms (age-adjusted OR (aOR) 6.49, 95% CI 3.03 to 14.1), comorbidity count (aOR 1.11 per comorbidity, 95% CI 1.02 to 1.21) and osteoarthritis (aOR 2.11, 95% CI 1.01 to 4.27). COVID-19 onset in 2021 vs June 2020 or earlier was associated with lower odds of prolonged symptom duration (aOR 0.42, 95% CI 0.21 to 0.81).

CONCLUSION

Most people with SARDs had complete symptom resolution by day 15 after COVID-19 onset. However, about 1 in 4 experienced COVID-19 symptom duration 28 days or longer; 1 in 10 experienced symptoms 90 days or longer. Future studies are needed to investigate the possible relationships between immunomodulating medications, SARD type/flare, vaccine doses and novel viral variants with prolonged COVID-19 symptoms and other postacute sequelae of COVID-19 among people with SARDs.

Tracking the source of contaminant lead in children's blood

Pb isotope ratios are used for apportioning the sources of Pb in the blood of children (ages 1-6) screened for high blood Pb levels (>5 μg/dL) surrounding urban areas of Kansas City, MO. We compared Pb isotope ratios measured in the child's blood with those of the most likely sources of Pb in that child's home environment. The environmental sources sampled consisted of topsoils, paints, occupational sources (e.g., oil rig workers' uniforms, mechanics' clothes), indoor air filters, dusts, and dietary sources (e.g., spices). Blood lead levels (BLL) ranged from 2.9 to 12.7 μg/dL in children from the five homes participating in this study. Measurements of ²⁰⁶Pb/²⁰⁴Pb, ²⁰⁷Pb/²⁰⁴Pb and ²⁰⁸Pb/²⁰⁴Pb isotope ratios were made by multi-collector ICP-MS. Comparison of the Pb isotope ratios in home environment samples versus those in the child's blood in each home allowed the identification of possible sources of a child's Pb exposure in three homes. In five homes investigated, children's blood Pb levels were most likely to be derived from dusts inside, and topsoil outside, the homes, or a mixture thereof. In one case, blood Pb was derived from turmeric spice and, in another, the Pb was derived from paint. It is not always possible to directly link high BLLs to the environmental sources collected when Pb isotope ratios of the environmental samples did not overlap with those of the blood.

Mild to moderate decrease in eGFR and cognitive decline in older adults

BACKGROUND

Whether mild to moderately low estimated glomerular filtration rate (eGFR) is associated with cognitive decline in older adults is not clear. We evaluated changes in cognition in relation to baseline eGFR in older adults participating in the Alzheimer's Disease Neuroimaging Initiative (ADNI).

METHODS

This is a longitudinal secondary analysis of an established observational cohort. We used data from the ADNI, an National Institutes of Health-funded, multicenter longitudinal observational study that includes participants with and without cognitive impairment who were administered a comprehensive battery of neuropsychological tests every 6 months. We related the Chronic Kidney Disease Epidemiology Collaboration eGFR with previously validated cognition composite scores for memory (ADNI-Mem) and executive function (ADNI-EF) in multivariable linear regression analysis adjusted for age, sex, race and level of education.

RESULTS

A total of 1127 ADNI participants (mean age 74 ± 7 years, 57% men, 97% Caucasian, mean follow-up 6 ± 2.6 years) were included in the analysis. The mean baseline eGFR was 76 ± 19 mL/min/1.73 m2, with 6% with eGFR <45, 22% with eGFR 45-<60, 51% with eGFR 60-90 and 21% with eGFR >90 mL/min/1.73 m2 at baseline. Both ADNI-Mem and ADNI-EF scores declined over time. In the multivariable linear regression model, older age (β = -0.117, P = 0.01), female sex (β = 0.312, P < 0.001) and lower education (β = 0.079, P < 0.001) were associated with a decline in ADNI-Mem scores, whereas baseline eGFR (each 10 mL/min/1.73 m2 change) was not {β = -0.03 [confidence interval (CI) -0.06-0.001], P = 0.11}. Similarly, older age (β = -0.278, P < 0.001) and lower education (β = 0.099, P < 0.001) were associated with a decline in ADNI-EF scores, whereas baseline eGFR was not [β = 0.004 (95% CI -0.04-0.04), P = 0.84].

CONCLUSIONS

In this cohort from the ADNI study, there was no association between baseline eGFR and cognitive decline in older adults with mild to moderately low eGFR.

Ceftriaxone Versus Cefazolin for the Treatment of Methicillin-Susceptible Staphylococcus aureus Bacteremia

BACKGROUND

Few studies have evaluated the use of ceftriaxone (CRO) in the treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections. The purpose of this study was to compare the safety and efficacy of CRO versus cefazolin (CFZ) for patients with MSSA bacteremia.

METHODS

This was a multi-center, single health-system retrospective study. Adult inpatients were included if they had a primary episode of MSSA bacteremia and received CRO or CFZ as definitive therapy. The primary endpoint was clinical cure at 7, 10, 14, and 28 days, or discharge, whichever came first. Secondary endpoints included treatment failure at 90 days, time to treatment failure, readmission due to recurrent MSSA bacteremia, duration of bacteremia, discontinuation of treatment due to adverse drug events, and Clostridioides difficile infection.

RESULTS

A total of 248 patients were included, of which 87 (35.1%) received CRO and 161 (64.9%) received CFZ. There was no difference in the primary outcome between the CRO group and the CFZ group (75 (86.2%) vs 145 (90.1%); p = 0.359), even after adjusting for Charlson Comorbidity Index and Pitt bacteremia score (aOR=1.35, 95% CI 0.58 -3.12; p = 0.49). There were no differences in time to clinical cure, treatment failure at 90 days, or safety events between the two groups.

CONCLUSION

Our findings suggest no clinical difference between CRO and CFZ for the definitive treatment of MSSA bacteremia. Further prospective studies are needed to confirm these findings.

Characteristics and Treatment Patterns of Patients with Type 2 Diabetes Mellitus in the Middle East and Africa Cohort of the DISCOVER Study Program: a Prospective Study

INTRODUCTION

Despite the high prevalence of type 2 diabetes (T2D) and suboptimal glycemic control in the Middle East and Africa, comprehensive data on the management of T2D remain scarce. The main aim of this study is to describe the characteristics and treatment of patients with T2D initiating second-line glucose-lowering therapy in these regions.

METHODS

DISCOVER is a global, 3-year, prospective observational study of patients with T2D enrolled at initiation of second-line glucose-lowering therapy. Baseline characteristics and treatments are presented for patients from 12 countries divided into three regions: Mediterranean, Gulf Cooperation Council, and South Africa.

RESULTS

Among 3525 patients (52.5% male, mean age 54.3 years), mean time since T2D diagnosis was 6.2 years [across-region range (ARR) 5.8-7.5 years] and mean glycated hemoglobin levels were 8.7% (72.0 mmol/mol) [ARR 8.6-9.0% (68-75 mmol/mol)]. At first line, metformin was prescribed for 88.1% (ARR 85.4-90.3%) of patients and a sulfonylurea for 34.4% (ARR 12.7-45.4%). Sulfonylureas and dipeptidyl peptidase-4 inhibitors were prescribed at second line for 55.5% (ARR 48.6-82.5%) and 49.0% (ARR 3.7-73.8%) of patients, respectively. Main reasons for choice of second-line therapy were efficacy (73.2%; ARR 60.1-77.7%) and tolerability (26.8%; ARR 3.7-31.2%).

CONCLUSIONS

We demonstrate considerable inter-region variations in the management of T2D, likely affected by multiple factors (health system, physician behavior, and patient compliance), all of which should be addressed to optimize outcomes.

Comparison of the Safety of Left Atrial Appendage Occlusion in Patients Aged <75 Versus Those Aged ≥75 Years (from a Nationwide Cohort Sample)

The mean age in clinical trials of percutaneous left atrial appendage occlusion (LAAO) has been <75 years. We aimed to better understand the safety of LAAO in older patients. National Inpatient Sample and International Classification of Diseases, Tenth Revision codes were used to identify patients with atrial fibrillation who underwent LAAO during the years 2016-2018. Patients were grouped by age <75 and ≥75 years. Baseline characteristics; length of stay; cost; hospital mortality; and other adverse events, including hematoma, vascular complications, perforation/tamponade, and stroke/ transient ischemic attack, were compared for the 2 groups. A total of 6,877 patients were identified, of whom 4,160 (60.4%) were aged ≥75 years. Length of stay and hospitalization costs were similar for the 2 groups. There were 10 deaths in patients aged ≥75 years and 1 death in patients aged <75 years (p = 0.059). The incidence of perforation/tamponade was 1.3% in patients aged ≥75 years versus 0.6% for those <75 years (p = 0.008). This difference persisted on multivariate analysis (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.01 to 3.07). The risk of perforation/tamponade was also higher in female patients (OR 2.74, 95% CI 1.63 to 4.59). There was a trend toward higher combined procedure-related adverse events (OR 1.46, 95% CI 0.99 to 2.15) in patients ≥75 years. There was no difference in the individual components of hematoma, vascular complication, and stroke/transient ischemic attack between both groups. In conclusion, percutaneous LAAO was associated with a higher risk of perforation and tamponade in older patients, particularly women.

Baseline Factors Associated with Self-reported Disease Flares Following COVID-19 Vaccination among Adults with Systemic Rheumatic Disease: Results from the COVID-19 Global Rheumatology Alliance Vaccine Survey

OBJECTIVE

To examine the frequency of, and risk factors for, disease flare following COVID-19 vaccination in patients with systemic rheumatic disease (SRD).

METHODS

An international study was conducted from April 2 to August 16, 2021, using an online survey of 5619 adults with SRD for adverse events following COVID-19 vaccination, including flares of disease requiring a change in treatment. We examined risk factors identified a priori based on published associations with SRD activity and SARS-CoV-2 severity, including demographics, SRD type, comorbidities, vaccine type, cessation of immunosuppressive medications around vaccination, and history of reactions to non-COVID-19 vaccines, using multivariable logistic regression.

RESULTS

Flares requiring a change in treatment following COVID-19 vaccination were reported by 4.9% of patients. Compared with rheumatoid arthritis, certain SRD, including systemic lupus erythematosus (OR 1.51, 95%CI 1.03, 2.20), psoriatic arthritis (OR 1.95, 95%CI 1.20, 3.18), and polymyalgia rheumatica (OR 1.94, 95%CI 1.08, 2.48) were associated with higher odds of flare, while idiopathic inflammatory myopathies were associated with lower odds for flare (OR 0.54, 95%CI 0.31-0.96). The Oxford-AstraZeneca vaccine was associated with higher odds of flare relative to the Pfizer-BioNTech vaccine (OR 1.44, 95%CI 1.07, 1.95), as were a prior reaction to a non-COVID-19 vaccine (OR 2.50, 95%CI 1.76, 3.54) and female sex (OR 2.71, 95%CI 1.55, 4.72).

CONCLUSION

SRD flares requiring changes in treatment following COVID-19 vaccination were uncommon in this large international study. Several potential risk factors, as well as differences by disease type, warrant further examination in prospective cohorts.

Assessment of cardiac recovery in patients supported with venoarterial extracorporeal membrane oxygenation

Aims

Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) is increasingly being used to support patients in cardiogenic shock (CS). Early determination of disposition is paramount, as longer durations of support have been associated with worse outcomes. We describe a stepwise, bedside weaning protocol to assess cardiopulmonary recovery during VA‐ECMO.

Methods and results

Over 1 year, we considered all patients on VA‐ECMO for CS for the Weaning Protocol (WP) at our centre. During the WP, patients had invasive haemodynamic monitoring, echocardiography, and blood gas analysis while flow was reduced in 1 LPM decrements. Ultimately, the circuit was clamped for 30 min, and final measures were taken. Patients were described as having durable recovery (DR) if they were free of pharmacological and mechanical support at 30 days post‐decannulation. Over 12 months, 34 patients had VA‐ECMO for CS. Fourteen patients were eligible for the WP at 4–12 days. Ten patients tolerated full flow reduction and were successfully decannulated. Twenty‐four per cent of the entire cohort demonstrated DR with no adverse events during the WP. Patients with DR had significantly higher ejection fraction, cardiac index, and smaller left ventricular size at lowest flow during the WP.

Conclusions

We describe a safe, stepwise, bedside weaning protocol to assess cardiac recovery during VA‐ECMO. Early identification of patients more likely to recover may improve outcomes during ECMO support.

Responsiveness of the HUG-5 in an outpatient clinic: a 12-month randomised feasibility study protocol

INTRODUCTION

Glaucoma is a progressive, chronic condition that can have a significant impact on a patient's health-related quality of life (HRQoL). Validated, disease-specific HRQoL tools such as the Health Utility for Glaucoma (HUG-5) tool and the Glaucoma Quality of Life Questionnaire (GlauQoL-17) can be used to monitor a patient's quality of life. However, the utility of these tools in outpatient clinic practice is not well established. The primary objective of this study is to characterise the feasibility of administering periodic HRQoL questionnaires in glaucoma using a semi-automated workflow.

METHODS AND ANALYSIS

This study will be a single-centre, unblinded, randomised, parallel-group study with an exploratory data analysis framework. We aim to determine the feasibility of administering the HUG-5 in an outpatient clinic using a semi-automated workflow and determine patient engagement through email and telephone contact methods. We will also be investigating the association of the HUG-5 and GlauQoL-17 with patient visual field testing and visual acuity. Mean differences between groups will be tested with analysis of variance to determine if the frequency of calls affects burden, satisfaction and perceived value of information.

ETHICS AND DISSEMINATION

This study has been approved by the Hamilton Integrated Research Ethics board (ID: 13046) and will be conducted within Canadian Tri-Council Statement policy. Personal information of the study's participants will be anonymised with identification codes and data will be kept on an encrypted server. Results of this study will be disseminated through peer-reviewed journals, conferences and internal meetings.

Outcomes With Phosphodiesterase-5 Inhibitor Use After Left Ventricular Assist Device: An STS-INTERMACS Analysis

BACKGROUND

Elevated right ventricular afterload following continuous-flow left ventricular assist device (CF-LVAD) may contribute to late right heart failure (LRHF). PDE5i (phosphodiesterase-5 inhibitors) are used to treat pulmonary hypertension and right heart dysfunction after CF-LVAD, but their impact on outcomes is uncertain.

METHODS

We queried Interagency Registry for Mechanically Assisted Circulatory Support from 2012 to 2017 for adults receiving a primary CF-LVAD and surviving ≥30 days from index discharge. Patients receiving early PDE5i (ePDE5i) at 1 month were propensity-matched 1:1 with controls. The primary outcome was the cumulative incidence of LRHF, defined using prevailing Interagency Registry for Mechanically Assisted Circulatory Support criteria; secondary outcomes included all-cause mortality and major bleeding.

RESULTS

Among 9627 CF-LVAD recipients analyzed, 2463 (25.6%) received ePDE5i and 1600 were propensity-matched 1:1 with controls. Before implant, ePDE5i patients had more severe RV dysfunction (13.1% versus 9.6%) and higher pulmonary vascular resistance (2.8±2.7 versus 2.2±2.4 WU), both P<0.001, but clinical factors were well-balanced after propensity-matching. In the unmatched cohort, ePDE5i patients had a higher 3-year cumulative incidence of LRHF, mortality, and major bleeding, but these differences were attenuated in the propensity-matched cohort: LRHF 40.8% versus 35.7% (hazard ratio, 1.14 [95% CI, 0.99-1.32]; P=0.07); mortality 38.6% versus 35.8% (hazard ratio, 0.99 [95% CI, 0.86-1.15]; P=0.93); major bleeding 51.2% versus 46.0% (hazard ratio, 1.12 [95% CI, 0.99-1.27]; P=0.06).

CONCLUSIONS

Compared with propensity-matched controls, adult CF-LVAD patients receiving ePDE5i had similar rates of LRHF, mortality, and major bleeding. While intrinsic patient risk factors likely account for more adverse outcomes with ePDE5i in the unmatched cohort, there is no obvious benefit of ePDE5i in the LVAD population.

In-Hospital Cardiac Arrest Survival in the United States During and After the Initial Novel Coronavirus Disease 2019 Pandemic Surge

BACKGROUND

Recent reports on challenges in resuscitation care at hospitals severely affected by the novel coronavirus disease 2019 (COVID-19) pandemic raise questions about how the pandemic affected outcomes for in-hospital cardiac arrest throughout the United States.

METHODS

Within Get With The Guidelines-Resuscitation, we conducted a retrospective cohort study to compare in-hospital cardiac arrest survival during the presurge (January 1-February 29), surge (March 1-May 15) and immediate postsurge (May 16-June 30) periods in 2020 compared to 2015 to 2019. Monthly COVID-19 mortality rates for each hospital's county were categorized, per 1 000 000 residents, as low (0-10), moderate (11-50), high (51-100), or very high (>100). Using hierarchical regression models, we compared rates of survival to discharge in 2020 versus 2015 to 2019 for each period.

RESULTS

Of 61 586 in-hospital cardiac arrests, 21 208 (4309 in 2020), 26 459 (5949 in 2020), and 13 919 (2686 in 2020) occurred in the presurge, surge, and postsurge periods, respectively. During the presurge period, 24.2% survived to discharge in 2020 versus 24.7% in 2015 to 2019 (adjusted odds ratio, 1.12 [95% CI, 1.02-1.22]). In contrast, during the surge period, 19.6% survived to discharge in 2020 versus 26.0% in 2015 to 2019 (adjusted odds ratio, 0.81 [0.75-0.88]). Lower survival was most pronounced in communities with high (28% lower survival) and very high (42% lower survival) monthly COVID-19 mortality rates (interaction P<0.001). Resuscitation times were shorter (median: 22 versus 25 minutes; P<0.001), and delayed epinephrine treatment was more prevalent (11.3% versus 9.9%; P=0.004) during the surge period. Survival was lower even when patients with confirmed/suspected COVID-19 infection were excluded from analyses. During the postsurge period, survival rates were similar in 2020 versus 2015 to 2019 (22.3% versus 25.8%; adjusted odds ratio, 0.93 [0.83-1.04]), including communities with high COVID-19 mortality (interaction P=0.16).

CONCLUSIONS

Early during the pandemic, rates of survival to discharge for IHCA decreased, even among patients without COVID-19 infection, highlighting the early impact of the COVID-19 pandemic on in-hospital resuscitation.

Diagnostic performance of volumetric laser endomicroscopy for Barrett's esophagus dysplasia amongst gastroenterology trainees

BACKGROUND

Volumetric laser endomicroscopy (VLE) is an advanced imaging modality used in Barrett's esophagus (BE) surveillance. VLE image interpretation is challenged by subtle grayscale image variation across a large amount of data. Training in VLE interpretation is not standardized. This study aims to determine if VLE training can be incorporated into a gastroenterology (GI) fellowship curriculum with the use of a self-directed module.

METHODS

A standardized, self-directed training module (30 min) was created explaining the background and established VLE criteria for the diagnosis of BE dysplasia. A VLE image dataset was generated from a multicenter VLE database of targeted biopsies. GI trainees were asked to grade each image for the presence or absence of the following criteria (I) increased surface optical frequency domain imaging (OFDI) signal intensity and (II) atypical glands and provide a final diagnosis (dysplastic vs. non-dysplastic). Diagnostic performance was calculated and results compared to VLE expert interpretation using histology as the gold-standard.

RESULTS

The dataset included 50 VLE images (10 high-grade dysplasia, 40 non-dysplastic BE). VLE images were reviewed in a randomized and blinded fashion by 5 GI trainees with no prior VLE experience and 5 experienced VLE users. Sensitivity, specificity and accuracy of GI trainees was 83.3% (95% CI: 71.5-91.7%), 59.0% (95% CI: 51.6-66.0%), and 64.8% (95% CI: 58.5-70.7%) compared to 80.0% (95% CI: 67.7-89.2%), 79.5% (95% CI: 73.0-85.0%), and 79.6% (95% CI: 74.1-84.4%) for VLE experts respectively. The difference in specificity and accuracy between the two groups were statistically significant with P<0.001.

CONCLUSIONS

A brief training session on VLE is inadequate to reach competency in interpretation of VLE by GI trainees. Additional experience is required to accurately interpret VLE images.

Morbidity and mortality in patients managed with high compared with low blood pressure targets during on-pump cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT.

SOURCE

We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings.

PRINCIPAL FINDINGS

We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials.

CONCLUSION

Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required.

STUDY REGISTRATION

PROSPERO (CRD42020177376); registered: 5 July 2020.

46. Templated Microbiology Comments with Candiduria to Enhance Antimicrobial Stewardship

Background

Behavioral interventions have been shown to improve antimicrobial selection. Such practices are low cost and effective means of stewardship promotion. One area of overtreatment that contributes to unnecessary antifungal use is in hospitalized patients with candiduria. We implemented a templated microbiology comment to guide prescribing of antifungals for hospitalized patients with candiduria.

Methods

This was a quasi-experimental, multi-center, single health system study. When Candida is isolated, the following comment appears in the microbiology result section along with the urine culture result: “In the absence of symptoms, Candida is generally considered normal flora. No therapy indicated unless high risk (pregnant, neonate or neutropenic) or undergoing urologic procedure. If Foley catheter present, remove or replace when able.” We compared a pre-implementation cohort (June 2018-Janurary 2019) to a post-implementation cohort (June 2019-Janurary 2020). Patients were included in the study if they were inpatients, 18 years and older, with candiduria. The primary outcome was the rate of antifungal administration within 72 hours after culture results became available. Secondary outcomes include duration of therapy and rate of antifungal given within 73-240 hours after culture result.

Results

The study included a total of 297 patients between the two groups (156 pre-implementation, 141 post-implementation). The primary outcome was found to be significantly lower in the post-implementation group (48.1% vs 34.0%, p=0.014). A multivariate adjustment for baseline characteristics that were significantly different between groups revealed that post-implementation group maintained its effect (OR 0.49 (0.29, 0.82), p=0.0067). For secondary outcomes, no difference was found in patients requiring antifungal administration within 73-240 hours after microbiology results were available (1.3% vs 3.5%, p=0.199). There was no difference in mean antifungal duration (4 vs 3 days, p=0.449).

Conclusion

Adding a templated comment to urine cultures was associated with a significant reduction in the number of antifungals prescribed in patients with candiduria. This strategy is an effective low-cost, passive education technique to improve antimicrobial stewardship.

Disclosures

All Authors: No reported disclosures

The 12- and 24-Month Effects of Intravitreal Ranibizumab, Aflibercept and Bevacizumab on Intraocular Pressure: A Network Meta-Analysis

TOPIC

To investigate the effect of anti-vascular endothelial growth factor (VEGF) intravitreal injections on intraocular pressure (IOP) 12- and 24-months after initiation.

CLINICAL RELEVANCE

It is unclear whether serial anti-VEGF injections result in sustained increases in IOP.

METHODS

Randomized control trials (RCTs) comparing anti-VEGF agents to each other or to a control for the treatment of neovascular age-related macular degeneration, retinal vein occlusions or diabetic macular edema were included. Pairwise meta-analysis and Bayesian network meta-analysis were performed examining the proportion of patients at 12- and 24-months whose IOP: a) increased ≥5mmHg from baseline on consecutive visits, b) increased ≥10mmHg from baseline at any visit, c) was ≥21mmHg on consecutive visits, d) was ≥25mmHg at any visit, e) was ≥30mmHg at any visit, f) prompted initiation of IOP lowering medications and g) increased as per the clinicians' discretion. Certainty of evidence was informed by Cochrane Collaboration's Risk of Bias Tool and GRADE (Grading of Recommendations Assessments, Development and Evaluations) guidelines.

RESULTS

26 RCTs of 12,522 eyes were included. Aflibercept (2.0mg), bevacizumab (1.25mg), ranibizumab (0.3mg and 0.5mg) and non-injection controls were analyzed. 83 of 84 network estimates for comparisons between anti-VEGF agents demonstrated no statistically significant difference between groups (low to moderate certainty of evidence). Ranibizumab 0.5mg had higher rates than bevacizumab of IOP measurements ≥30mmHg at 12-months (low certainty of evidence). 53 of 56 network estimates for comparisons between anti-VEGF agents and controls demonstrated no statistically significant difference between groups (low to moderate certainty of evidence). Ranibizumab 0.5mg had higher rates of consecutive IOP increases ≥ 5mmHg at 24-months (low certainty of evidence) and higher rates of IOP increases as per the clinicians' discretion at 12 and 24 months (low and very low certainty of evidence respectively). The 95% credible intervals in all comparisons without statistically significant effects did not rule out important clinical effects. The certainty of evidence in these comparisons is limited by imprecision.

CONCLUSION

Evidence from our network meta-analysis does not show any clear difference between anti-VEGF agents and controls when examining IOP increases 12- and 24-months after treatment initiation. Imprecision precludes definitive conclusions with the available data.

Treatment burden of robotic gastrectomy for locally advanced gastric cancer (LAGC): a single western experience

Background

This study compares standard of care (SOC) open and robotic D2-gastrectomy for locally advanced gastric cancer (LAGC) in the Western context of low disease prevalence, reduced surgical volume, and neoadjuvant chemotherapy (NAC). We hypothesized that robotic gastrectomy (RG) after NAC reduces treatment burden for LAGC across multiple outcome domains vs. SOC.

Methods

Single institution, interrupted time series comparing SOC (2008–2013) for LAGC (T2–4Nany/TanyN+) vs. NAC + RG (2013–2018). Treatment burden was a composite metric of narcotic consumption, oncologic efficacy, cumulative morbidity, and 90-day resource utilization. Predictors were evaluated via multivariate modeling. Learning curve analysis was done using CUSUM.

Results

After exclusions, 87 subjects with equivalent baseline characteristics, aside from male sex, were treated via SOC (n=55) or NAC + RG (n=32). All four domains of treatment burden were significantly reduced in the NAC + RG cohort compared to SOC (P=0.003). The odds ratio for excess treatment burden in the NAC/RG was 0.23 (95% CI: 0.07–0.72, P=0.0117) vs. SOC upon multivariable modeling, whereas the extent of resection (total/subtotal), tumor size, T-stage, sex, and early learning curve had no effect. Differences in treatment burden persisted in subgroup analysis for NAC (n=51).

Conclusions

NAC + RG was associated with decreased treatment burden relative to SOC for LAGC. Frequencies of unfavorable hospitalization, adverse oncological outcomes, major morbidity, and narcotic consumption all decreased in this interrupted time series.

Impact of telehealth in the outpatient management of atrial fibrillation during the COVID-19 pandemic

Background

The COVID-19 pandemic accelerated adoption of a telehealth model to replace outpatient visits. We studied quality indicators and clinical outcomes associated with virtual visits in comparison to in-person ambulatory visits for patients with atrial fibrillation (AF) seen by electrophysiology providers.

Methods

Quality indicators and outcomes for patients with primary diagnosis of AF seen by electrophysiology providers (6 physicians and 4 nurse practitioners) for the 12 week period of March 22–June 13, 2020 were compared with those from the 12 week period of March 24–June 15, 2019.

Result

We identified 2340 clinic visits for AF (1081 in 2019 and 1259 in 2020). Telehealth was not used in 2019, and was used in 90.5% of the 2020 visits. On multivariate analysis during 120 days following each encounter, there was no difference in hospital admissions between 2019 and 2020 (OR 0.89; 95% CI 0.69–1.14; p=0.3624), and there was trend towards lower emergency department visits in 2020 compared with 2019 (OR 0.77; 95% CI 0.6–1; p=0.0509). There were 36 deaths at 120 days, mortality was similar in 2020 as compared with 2019 (OR 1.5; 95% CI 0.74–3.03; p=0.2601). There was no difference in completed procedures including permanent pacemakers, cardiac resynchronization therapy devices, implantable cardioverter-defibrillators and catheter ablations. There was a significant difference in anticoagulant (OR 0.71; 95% CI 0.52–0.99; p=0.0412) and antiarrhythmic (OR 0.78; 95% CI 0.61–0.99; p=0.0384) dose adjustment or new prescriptions in 2019 compared with 2020.

Conclusion

Telehealth was associated with similar intermediate-term clinical outcomes when compared to traditional ambulatory encounters. However, adjusting or providing new prescriptions for anticoagulant or anti-arrhythmic medications was more common with in-person than with virtual visits.

Funding Acknowledgement

Type of funding sources: None.

External validation of blue light imaging (BLI) criteria for the optical characterization of colorectal polyps by endoscopy experts

BACKGROUND AND AIM

Recently, the BLI Adenoma Serrated International Classification (BASIC) system was developed by European experts to differentiate colorectal polyps. Our aim was to validate the BASIC classification system among the US-based endoscopy experts.

METHODS

Participants utilized a web-based interactive learning system where the group was asked to characterize polyps using the BASIC criteria: polyp surface (presence of mucus, regular/irregular and [pseudo]depressed), pit appearance (featureless, round/non-round with/without dark spots; homogeneous/heterogeneous distribution with/without focal loss), and vessels (present/absent, lacy, peri-cryptal, irregular). The final testing consisted of reviewing BLI images/videos to determine whether the criteria accurately predicted the histology results. Confidence in adenoma identification (rated "1" to "5") and agreement in polyp (adenoma vs non-adenoma) identification and characterization per BASIC criteria were derived. Strength of interobserver agreement with kappa (k) value was reported for adenoma identification.

RESULTS

Ten endoscopy experts from the United States identified conventional adenoma (vs non-adenoma) with 94.4% accuracy, 95.0% sensitivity, 93.8% specificity, 93.8% positive predictive value, and 94.9% negative predictive value using BASIC criteria. Overall strength of interobserver agreement was high: kappa 0.89 (0.82-0.96). Agreement for the individual criteria was as follows: surface mucus (93.8%), regularity (65.6%), type of pit (40.6%), pit visibility (66.9%), pit distribution (57%), vessel visibility (73%), and being lacy (46%) and peri-cryptal (61%). The confidence in diagnosis was rated at high ≥4 in 67% of the cases.

CONCLUSIONS

A group of US-based endoscopy experts have validated a simple and easily reproducible BLI classification system to characterize colorectal polyps with >90% accuracy and a high level of interobserver agreement.