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BACKGROUND: Malnutrition in hospitalized patients is associated increased length of stay, cost, readmission, and death. No recent studies have examined trends in prevalence or outcomes of hospitalized patients with a diagnosis of malnutrition. OBJECTIVES: To study the prevalence of malnutrition diagnostic codes and associated hospital outcomes in the United States between 2016 and 2019. METHODS: We conducted a retrospective trends study to identify use of malnutrition codes in hospitalizations in the National Inpatient Sample between 2016 and 2019. We used direct standardization by logistic regression to adjust outcomes of percutaneous gastrostomy tube placement, mechanical ventilation, and death for age, Gagne comorbidity score, and sex. We then used linear regression to test for trends over time by malnutrition type. RESULTS: Across all hospitalizations, codes for diagnoses of non-severe malnutrition and severe malnutrition were present in 3.7% and 4.1% of hospitalizations, respectively. Codes for any malnutrition increased over time, from 6.6% in 2016 to 8.6% in 2018 (p = .03). Codes for severe malnutrition increased from 3.3% to 4.7% (p = .01). Among hospitalizations with coded severe malnutrition diagnoses, there was a statistically significant decrease in adjusted rate of death over time (-0.54% per year, p = .03) which was not seen in hospitalizations without coded malnutrition diagnoses. CONCLUSIONS: Use of malnutrition diagnosis codes increased significantly from 2016 to 2019. During this time, mortality among hospitalizations with a diagnosis code for severe malnutrition decreased. Though the increased prevalence of malnutrition codes may represent a change in the clinical characteristics of hospitalized patients, the decline in mortality suggests some of the increase may be due to lower threshold for coding and assignment of the diagnosis to less ill patients.
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OBJECTIVES: To develop an electronic descriptor of clinical deterioration for hospitalized patients that predicts short-term mortality and identifies patient deterioration earlier than current standard definitions. DESIGN: A retrospective study using exploratory record review, quantitative analysis, and regression analyses. SETTING: Twelve-hospital community-academic health system. PATIENTS: All adult patients with an acute hospital encounter between January 1, 2018, and December 31, 2022. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Clinical trigger events were selected and used to create a revised electronic definition of deterioration, encompassing signals of respiratory failure, bleeding, and hypotension occurring in proximity to ICU transfer. Patients meeting the revised definition were 12.5 times more likely to die within 7 days (adjusted odds ratio 12.5; 95% CI, 8.9-17.4) and had a 95.3% longer length of stay (95% CI, 88.6-102.3%) compared with those who were transferred to the ICU or died regardless of meeting the revised definition. Among the 1812 patients who met the revised definition of deterioration before ICU transfer (52.4%), the median detection time was 157.0 min earlier (interquartile range 64.0-363.5 min). CONCLUSIONS: The revised definition of deterioration establishes an electronic descriptor of clinical deterioration that is strongly associated with short-term mortality and length of stay and identifies deterioration over 2.5 hours earlier than ICU transfer. Incorporating the revised definition of deterioration into the training and validation of early warning system algorithms may enhance their timeliness and clinical accuracy.
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Deterioro Clínico , Unidades de Cuidados Intensivos , Transferencia de Pacientes , Humanos , Masculino , Transferencia de Pacientes/estadística & datos numéricos , Estudios Retrospectivos , Femenino , Persona de Mediana Edad , Anciano , Mortalidad Hospitalaria , Tiempo de Internación/estadística & datos numéricos , AdultoRESUMEN
BACKGROUND: Respiratory syncytial virus (RSV), human metapneumovirus (hMPV), and parainfluenza virus (PIV) hospitalize many people yearly. Though severe lower respiratory tract disease has been described in children, the elderly, and the immunocompromised, there is a gap in our understanding of RSV, hMPV, and PIV in hospitalized adults. We sought to evaluate the association of RSV, hMPV, and PIV with severe respiratory disease requiring noninvasive or mechanical ventilation and death in hospitalized adults in the United States. METHODS: We conducted a retrospective, pooled, cross-sectional study of general medicine hospitalizations in the United States from 2016 to 2019 using the National Inpatient Sample published by the Agency for Healthcare Quality and Research. We used multivariable Poisson regression to estimate the likelihood of severe respiratory disease or death. We used linear regression to estimate the mean difference in length of stay for those hospitalized with and without a respiratory virus. RESULTS: We found that RSV (incidence rate ratio [IRR]: 1.68, 95% confidence interval [CI]: 1.61-1.74, p < .001), hMPV (IRR: 1.82, 95% CI: 1.71-1.93, p < .001), and PIV (IRR: 1.81, 95% CI: 1.68-1.94, p < .001) were independently associated with severe respiratory disease, even after adjustment. Additionally, we found the presence of a respiratory virus prolonged hospitalizations by (0.79 ± 0.27 days, p < .003) for RSV, (0.88 ± 0.28 days, p < .002) for hMPV, and (1.43 ± 0.30 days, p < .001) for PIV. CONCLUSIONS: RSV, hMPV, and PIV have a significant burden on hospitalized adults, even without classic risk factors.
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Hospitalización , Metapneumovirus , Infecciones por Paramyxoviridae , Infecciones por Virus Sincitial Respiratorio , Humanos , Estados Unidos/epidemiología , Infecciones por Virus Sincitial Respiratorio/epidemiología , Masculino , Femenino , Estudios Transversales , Estudios Retrospectivos , Metapneumovirus/aislamiento & purificación , Infecciones por Paramyxoviridae/epidemiología , Persona de Mediana Edad , Hospitalización/estadística & datos numéricos , Adulto , Anciano , Virus Sincitial Respiratorio Humano/aislamiento & purificación , Tiempo de Internación/estadística & datos numéricosRESUMEN
Point of care ultrasound (POCUS) is a portable and accessible tool that has immense potential in low- and middle-income countries (LMIC) for diagnostic accuracy and medical education. We implemented a hybrid in-person and virtual training curriculum to teach providers in Belize the basic techniques of lung ultrasound in the diagnosis of pneumonia. Between August 2021 and June 2022, a total of eleven lung scans were performed at Hillside Clinic for patients presenting with respiratory complaints. Deidentified images were shared via the ButterflyIQ web platform to POCUS experts in the United States. We found that training was solidified through virtual, immediate feedback using the common interfaces Butterfly iQ + and WhatsApp to share images and guide diagnostic reasoning. The aim of this review study is to share our experience and challenges in the implementation of a POCUS training curriculum in an LMIC, provide an example of training methodology that can be effective, and discuss how this can be implemented and modified for clinicians in similar settings.
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COVID-19 , Humanos , Consentimiento Informado , Posición Prona , Respiración Artificial , SARS-CoV-2RESUMEN
A diabetic foot ulcer is present in approximately 2.4% of hospitalized patients. Care for diabetic foot ulcers is highly variable. We sought to describe care practice patterns and risk factors for poor outcomes for patients hospitalized with a diabetic foot ulcer in our institution, an 894-bed tertiary care academic hospital located in downtown Chicago, IL. We conducted a retrospective cohort study of patients hospitalized with a diabetic foot ulcer between March 3rd, 2018 and December 31st, 2019. We categorized patients into having an uncomplicated ulcer or a complicated ulcer with cellulitis, wound infection, osteomyelitis, or gangrene. We evaluated rates of diagnostic resource utilization (imaging, cultures, biopsies, and antibiotics) and outcomes of osteomyelitis, amputation, and death. There were 305 patients of interest in the study cohort. A complicated lower extremity ulcer was found in 79% of patients. Amputation was required in 25% of patients, 21% were readmitted, and 13% died. Imaging was obtained in less than 50% of all patients, and in 60% or less of those with osteomyelitis. Bone biopsies were rarely acquired. Empiric antibiotics were prescribed in 77% of patients with osteomyelitis. Male, Black or African-American patients, and those with high Charlson score had the highest risk of poor outcomes. Care practices for patients hospitalized with diabetic foot ulcers were highly variable. Future interventions should target standardization to improve outcomes, with particular attention to health inequities as vulnerable populations have a higher risk of poor outcomes.
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Diabetes Mellitus , Pie Diabético , Osteomielitis , Humanos , Masculino , Pie Diabético/complicaciones , Pie Diabético/terapia , Pie Diabético/diagnóstico , Estudios Retrospectivos , Centros de Atención Terciaria , Osteomielitis/complicaciones , Osteomielitis/terapia , Antibacterianos/uso terapéutico , Diabetes Mellitus/tratamiento farmacológicoRESUMEN
OBJECTIVES: To describe organisms most frequently identified on bone biopsy or deep tissue culture and determine how culture data impacted antibiotic management in patients with diabetic foot osteomyelitis (DFO). METHODS: We retrospectively reviewed patients admitted with a diabetic foot ulcer (DFU) between 3 March 2018 and 31 December 2019 and selected for patients diagnosed with infectious osteomyelitis (OM) of the lower extremity. We stratified patients by whether a bone biopsy or deep tissue culture was obtained and compared rates of antibiotic utilization with chi-squared and Fisher's exact tests. RESULTS: Of 305 patients with a DFU, 152 (50%) were clinically diagnosed with DFO. Forty-seven patients received 41 deep tissue cultures and 29 bone biopsy cultures for a total of 70 cultures. Of 45 (64%) positive cultures, 36 (80%) had Gram-positive organisms and 19 (42%) had Gram-negative organisms. MDR organisms were isolated in 7 (15%) patients. Culture data resulted in antibiotic changes in 41 (87%) patients. Therapy was narrowed in 29 (62%) patients and broadened due to inadequate empirical coverage in 4 (9%) patients. Culture data from 18 (40%) patients showed susceptibility to an oral treatment regimen with high bioavailability. There was no significant difference in rates of antibiotic utilization at discharge between patients who underwent bone biopsy or deep tissue culture relative to those who did not (77% versus 75%, Pâ=â0.86), although less MRSA coverage was used (34% versus 50%, Pâ=â0.047). CONCLUSIONS: In patients with DFO, deep tissue and bone biopsy cultures were infrequently obtained but resulted in targeted therapy changes in most patients. Culture data usually allowed for narrowing of antibiotics but revealed inadequate empirical coverage in a subset of patients.
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Programas de Optimización del Uso de los Antimicrobianos , Diabetes Mellitus , Pie Diabético , Osteomielitis , Humanos , Pie Diabético/complicaciones , Pie Diabético/tratamiento farmacológico , Estudios Retrospectivos , Osteomielitis/tratamiento farmacológico , Antibacterianos/uso terapéutico , Biopsia/métodosRESUMEN
A 23-year-old previously healthy male presented to the hospital with symptoms of heart failure. He was diagnosed with pericarditis and found to have a reduced left ventricular ejection fraction of 25%. He was noted to have mediastinal lymphadenopathy. Pulmonary and abdominal sampling were non-diagnostic for infection, autoimmune disease, or malignancy. A QuantiFERON Gold returned positive. After a thorough travel history and detailed exam, the patient was diagnosed with disseminated tuberculosis after the discovery of a cutaneous gumma that was found to have acid-fast bacilli present on biopsy with Fite's stain. 18F-FDG PET CT and cardiac MRI were pursued given that pericardial and myocardial biopsy could not be safely performed due to the patient's hemodynamics. 18F-FDG PET CT and cardiac MRI did not demonstrate any myocardial pathology responsible for the left ventricular ejection fraction. This case highlights that pulmonary involvement is not necessary for disseminated TB, Fite's stain may be used to identify M. tuberculosis, and that cardiac MRI and 18F-FDG PET CT may be useful to delineate myocardial involvement in high-risk situations.
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Mycobacterium tuberculosis , Pericarditis Constrictiva , Tuberculosis , Adulto , Fluorodesoxiglucosa F18 , Humanos , Masculino , Pericarditis Constrictiva/diagnóstico , Pericarditis Constrictiva/diagnóstico por imagen , Volumen Sistólico , Tuberculosis/complicaciones , Función Ventricular Izquierda , Adulto JovenRESUMEN
BACKGROUND: We present a yet to be described association of SARS-CoV-2 infection with Kikuchi-Fujimoto disease. CASE PRESENTATION: A 32-year-old physician with history of SARS-CoV-2 infection presented to the emergency department with 2 weeks of fever, chills, and right sided cervical lymphadenopathy. He was treated empirically for presumed folliculitis with worsening of symptoms leading to repeat presentation to the emergency department. Extensive workup was unrevealing of an infectious cause and needle biopsy of the lesion was unrevealing. An excisional lymph node biopsy revealed follicular hyperplasia with necrotic foci showing abundance of histiocytes at the edge of necrosis with CD8 predominance of T-cells. Final diagnosis was deemed to be Kikuchi-Fujimoto disease. Antibiotic therapy was discontinued, and the patient's symptoms resolved with steroid therapy and expectant management. CONCLUSIONS: This is the first report of a patient developing Kikuchi-Fujimoto disease following SARS-CoV-2 infection. Clinicians should be aware of Kikuchi-Fujimoto disease as a possibility when approaching patients with hyper-inflammatory states who present with cervical lymphadenopathy.
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COVID-19 , Linfadenitis Necrotizante Histiocítica , Linfadenopatía , Adulto , Diagnóstico Diferencial , Linfadenitis Necrotizante Histiocítica/complicaciones , Linfadenitis Necrotizante Histiocítica/diagnóstico , Humanos , Ganglios Linfáticos , Linfadenopatía/diagnóstico , Linfadenopatía/etiología , Masculino , SARS-CoV-2RESUMEN
The importance of exertional hypoxia without resting hypoxia in COVID-19 is unknown and may help objectively identify high-risk patients. Interventions may be initiated earlier with sufficient lead-time between development of exertional hypoxia and other outcome measures. We performed a retrospective study of adult patients hospitalized with COVID-19 from March 1, 2020 to October 30, 2020 in an integrated academic medical system in the Chicagoland area. We analyzed patients who had daily exertional oximetry measurements taken. We defined exertional hypoxia as SpO2 < 90% with ambulation. We excluded patients who had first exertional oximetry measurements or first exertional hypoxia after the use of oxygen therapies. We determined the association of exertional hypoxia without resting hypoxia with the eventual need for nasal cannula or advanced oxygen therapies (defined as high flow nasal cannula, Bi-PAP, ventilator, or extracorporeal membrane oxygenation). We also calculated the time between development of exertional hypoxia and the need for oxygen therapies. Of 531 patients included, 132 (24.9%) had exertional hypoxia. Presence of exertional hypoxia was strongly associated with eventual use of nasal cannula (OR 4.8, 95% CI 2.8-8.4) and advanced oxygen therapy (IRR 7.7, 95% CI 3.4-17.5). Exertional hypoxia preceded nasal cannula use by a median 12.5 h [IQR 3.25, 29.25] and advanced oxygenation by 54 h [IQR 25, 82]. Exertional hypoxia without resting hypoxia may serve as an early, non-invasive physiologic marker for the likelihood of developing moderate to severe COVID-19. It may help clinicians triage patients and initiate earlier interventions.