Thick Liquids and Clinical Outcomes in Hospitalized Patients With Alzheimer Disease and Related Dementias and Dysphagia.

Importance: Oropharyngeal dysphagia is common in hospitalized patients with Alzheimer disease and related dementias (ADRD). Although the use of thick liquids in patients with dysphagia has been shown to reduce aspiration on direct visualization, there is no clear evidence that this practice translates into improved clinical outcomes. Objectives: To determine whether a diet of thick liquids compared with thin liquids is associated with improved outcomes in hospitalized patients with ADRD and dysphagia. Design, Setting, and Participants: This cohort study included adults aged 65 years and older with ADRD who were admitted to the medicine service across 11 diverse hospitals in New York between January 1, 2017, and September 20, 2022, with clinical suspicion of dysphagia during hospitalization and survival for at least 24 hours after hospital arrival. Patients were grouped according to whether at least 75% of their hospital diet consisted of a thick liquid diet or a thin liquid diet. Propensity score matching was used to balance covariates across the 2 groups for the following covariates: demographics (eg, age, sex), baseline clinical characteristics (eg, Charlson Comorbidity Index), and acute presentation (eg, respiratory diagnosis, illness severity, delirium). Main Outcomes and Measures: Hospital outcomes included mortality (primary outcome), respiratory complications (eg, pneumonia), intubation, and hospital length of stay (LOS). Results: Of 8916 patients with ADRD and dysphagia included in the propensity score matched analysis, the mean (SD) age was 85.7 (8.0) years and 4829 were female (54.2%). A total of 4458 patients receiving a thick liquid diet were matched with 4458 patients receiving a thin liquid diet. There was no significant difference in hospital mortality between the thick liquids and thin liquids groups (hazard ratio, 0.92; 95% CI, 0.75-1.14]; P = .46). Compared with patients receiving thin liquids, patients receiving thick liquids were less likely to be intubated (odds ratio [OR], 0.66; 95% CI, 0.54-0.80), but they were more likely to have respiratory complications (OR, 1.73; 95% CI, 1.56-1.91). Conclusions and Relevance: This cohort study emphasizes the need for prospective studies that evaluate whether thick liquids are associated with improved clinical outcomes in hospitalized patients with ADRD and dysphagia.

Utilization of a Guideline-recommended Imaging Paradigm for Pregnant Patients With Suspicion of Pulmonary Embolism.

PURPOSE: A dose reduction imaging paradigm utilizing chest x-ray (CXR) to triage between computed tomography pulmonary angiography (CTPA) and lung scintigraphy (LS) was introduced in 2001 and adopted in 2012 by the American Thoracic Society/Society of Thoracic Radiology (ATS) guideline for the evaluation of pulmonary embolism in pregnancy. We aimed to assess the utilization of this imaging paradigm preadoption and postadoption by the ATS guideline, and identify factors associated with its utilization. MATERIALS AND METHODS: This retrospective cohort study evaluated consecutive pregnant patients who received CTPA or LS for the evaluation of pulmonary embolism in pregnancy at 2 tertiary hospitals between September 2008 and March 2017, excluding 2012 for guideline release washout. Utilization of the imaging paradigm was defined per patient by the use of CXR before advanced imaging, with CTPA performed following positive CXR and LS performed following negative CXR. Multivariate analyses were performed to assess factors associated with utilization of the imaging paradigm. P <0.05 is considered significant. RESULTS: Overall, 9.8% (63/643) of studies utilized the dose reduction imaging paradigm, 13.3% (34/256) before the guidelines, and 7.5% (29/387) after. Multivariable analysis showed that the dose reduction imaging paradigm utilization was higher for inpatients (odds ratio [OR]: 4.5) and outpatients (OR: 3.1) relative to the emergency department patients, and lower for second (OR: 0.3) and third (OR: 0.2) trimester patients, without significant differences by study priority, patient age, or patient race. CONCLUSIONS: Guideline-recommended dose reduction imaging paradigm utilization was low, and decreased after guideline publication. Utilization varied by patient setting and trimester, which are potential targets for interventions to improve guideline compliance.

Comparison of Chest Radiograph Impressions for Diagnosing Pneumonia: Accounting for Categories of Language Certainty.

OBJECTIVES: Uncertain language in chest radiograph (CXR) reports for the diagnosis of pneumonia is prevalent. The purpose of this study is to validate an a priori stratification of CXR results for diagnosing pneumonia based on language of certainty. DESIGN: Retrospective chart review. SETTING AND PARTICIPANTS: CXR reports of 2,411 patient visits ≥ 18 years, admitted to medicine, who received a CXR and noncontrast chest CT within 48 hours of emergency department registration at two large academic hospitals (tertiary and quaternary care) were reviewed. METHODS: The CXR and CT report impressions were categorized as negative, uncertain, or positive. Uncertain CXRs were further stratified into four categories based on language modifiers for the degree of pneumonia certainty. Comparison of CXR and CT results were determined using χ2 test; a P value of less than .0033 was considered significant to account for multiple comparisons. RESULTS: CXR reports for the diagnosis of pneumonia revealed the following distribution: 61% negative, 32% uncertain, and 7% positive; CT reports were 55% negative, 22% uncertain, and 23% positive for the diagnosis of pneumonia. There were significant differences between CXR categories compared with CT categories for diagnosis of pneumonia (P < .001). Negative CXR results were not significantly different than the uncertain category with the most uncertain language (P = .030) but were significantly different from all other uncertain categories and positive CXR results (each P < .001). Positive CXR results were not significantly different than the least uncertain category (most certain language) (P = .130) but were significantly different from all other categories (each P < .001). CONCLUSIONS AND IMPLICATIONS: Language used in CXR reports to diagnose pneumonia exists in categories of varying certainty and should be considered when evaluating patients for pneumonia.

Psychotropic Medication Use Is Associated With Greater 1-Year Incidence of Dementia After COVID-19 Hospitalization.

Background: COVID-19 has been associated with an increased risk of incident dementia (post-COVID dementia). Establishing additional risk markers may help identify at-risk individuals and guide clinical decision-making. Methods: We investigated pre-COVID psychotropic medication use (exposure) and 1-year incidence of dementia (outcome) in 1,755 patients (≥65 years) hospitalized with COVID-19. Logistic regression models were used to examine the association, adjusting for demographic and clinical variables. For further confirmation, we applied the Least Absolute Shrinkage and Selection Operator (LASSO) regression and a machine learning (Random Forest) algorithm. Results: One-year incidence rate of post-COVID dementia was 12.7% (N = 223). Pre-COVID psychotropic medications (OR = 2.7, 95% CI: 1.8-4.0, P < 0.001) and delirium (OR = 3.0, 95% CI: 1.9-4.6, P < 0.001) were significantly associated with greater 1-year incidence of post-COVID dementia. The association between psychotropic medications and incident dementia remained robust when the analysis was restricted to the 423 patients with at least one documented neurological or psychiatric diagnosis at the time of COVID-19 admission (OR = 3.09, 95% CI: 1.5-6.6, P = 0.002). Across different drug classes, antipsychotics (OR = 2.8, 95% CI: 1.7-4.4, P < 0.001) and mood stabilizers/anticonvulsants (OR = 2.4, 95% CI: 1.39-4.02, P = 0.001) displayed the greatest association with post-COVID dementia. The association of psychotropic medication with dementia was further confirmed with Random Forest and LASSO analysis. Conclusion: Confirming prior studies we observed a high dementia incidence in older patients after COVID-19 hospitalization. Pre-COVID psychotropic medications were associated with higher risk of incident dementia. Psychotropic medications may be risk markers that signify neuropsychiatric symptoms during prodromal dementia, and not mutually exclusive, contribute to post-COVID dementia.

A Novel Method to Improve the Identification of Time of Intubation for Retrospective EHR Data Analysis During a Time of Resource Strain, the COVID-19 Pandemic.

Accurate determinations of the time of intubation (TOI) are critical for retrospective electronic health record (EHR) data analyses. In a retrospective study, the authors developed and validated an improved query (Ti) to identify TOI across numerous settings in a large health system, using EHR data, during the COVID-19 pandemic. Further, they evaluated the affect of Ti on peri-intubation patient parameters compared to a previous method-ventilator parameters (Tv). Ti identified an earlier TOI for 84.8% (n = 1666) of cases with a mean (SD) of 3.5 hours (15.5), resulting in alternate values for: partial pressure of arterial oxygen (PaO 2 ) in 18.4% of patients (mean 43.95 mmHg [54.24]); PaO 2 /fractional inspired oxygen (FiO 2 ) in 17.8% of patients (mean 48.29 [69.81]), and oxygen saturation/FiO 2 in 62.7% (mean 16.75 [34.14]), using the absolute difference in mean values within the first 4 hours of intubation. Differences in PaO 2 /FiO 2 using Ti versus Tv resulted in the reclassification of 7.3% of patients into different acute respiratory distress syndrome (ARDS) severity categories.

Machine learning to assist clinical decision-making during the COVID-19 pandemic.

BACKGROUND: The number of cases from the coronavirus disease 2019 (COVID-19) global pandemic has overwhelmed existing medical facilities and forced clinicians, patients, and families to make pivotal decisions with limited time and information. MAIN BODY: While machine learning (ML) methods have been previously used to augment clinical decisions, there is now a demand for "Emergency ML." Throughout the patient care pathway, there are opportunities for ML-supported decisions based on collected vitals, laboratory results, medication orders, and comorbidities. With rapidly growing datasets, there also remain important considerations when developing and validating ML models. CONCLUSION: This perspective highlights the utility of evidence-based prediction tools in a number of clinical settings, and how similar models can be deployed during the COVID-19 pandemic to guide hospital frontlines and healthcare administrators to make informed decisions about patient care and managing hospital volume.

The Clinical Utility of Chest Radiography for Identifying Pneumonia: Accounting for Diagnostic Uncertainty in Radiology Reports.

OBJECTIVE. Currently, chest radiography is the first-line imaging test for identifying pneumonia; chest CT is considered the reference standard. The purpose of this study was to calculate the statistical measures of performance of chest radiography for identifying pneumonia when taking into account uncertain results of both chest radiography and CT examinations. MATERIALS AND METHODS. Statistical measures of performance of chest radiography, using CT as the reference standard, were calculated with 95% CIs by varying uncertain radiology report impressions of both chest radiography and CT to all negative or all positive. The resulting scenarios were as follows: scenario 1, uncertain chest radiography and CT impressions are considered positive for pneumonia; scenario 2, uncertain chest radiography impressions are positive but uncertain CT impressions are negative; scenario 3, uncertain chest radiography impressions are negative and uncertain CT impressions are positive; scenario 4, uncertain chest radiography and CT impressions are negative; and scenario 5, uncertain chest radiography and CT impressions are excluded. RESULTS. A retrospective analysis of 2411 patient visits revealed the prevalence of uncertain radiology report impressions to be 31.8% for chest radiography and 21.7% for CT. Scenario 1 yielded the following performance values: sensitivity, 51.9%; specificity, 71.3%; PPV, 59.4%; and NPV, 64.5%. Scenario 2 produced the following performance values: sensitivity, 59.6%; specificity, 67.1%; PPV, 59.6%; and NPV, 67.1%. Scenario 3 showed the following performance values: sensitivity, 13.4%; specificity, 97.7%; PPV, 82.6%; and NPV, 58.1%. Scenario 4 yielded the following performance values: sensitivity, 19.6%; specificity, 96.4%; PPV, 81.6%; and NPV, 59.5%. Scenario 5 produced the following performance values: sensitivity, 32.7%; specificity, 96.8%; PPV, 89.2%; and NPV, 63.8%. CONCLUSION. Uncertain chest radiography results for the evaluation of pneumonia are prevalent. A chest radiography impression using the strongest language in support of a pneumonia diagnosis is useful to rule in pneumonia radiographically, but a negative result performs poorly at ruling out disease.

Aspiration Pneumonia in Older Adults.

Aspiration pneumonia refers to an infection of the lung parenchyma in an individual that has inhaled a bolus of endogenous flora that overwhelms the natural defenses of the respiratory system. While there are not universally agreed upon criteria, the diagnosis can be made in patients with the appropriate risk factors and clinical scenario, in addition to a radiographic or an ultrasonographic image of pneumonia in the typical dependent lung segment. Treatment options for aspiration pneumonia vary based on the site of acquisition (community-acquired aspiration pneumonia [CAAP] versus healthcare-associated aspiration pneumonia [HCAAP]), the risk for multidrug-resistant (MDR) organisms, and severity of illness. Hospitalized CAAP patients without severe illness and with no risk for MDR organisms or Pseudomonas aeruginosa (PA) can be treated with standard inpatient community-acquired pneumonia therapy covering anaerobes. Patients with CAAP and either of the following-risk factors for MDR pathogens, septic shock, need for an intensive care unit (ICU) admission, or mechanical ventilation-can be considered for broader coverage against anaerobes, methicillin-resistant Staphylococcus aureus (MRSA), and PA. Severe aspiration pneumonia that originates in a long-term care facility or HCAAP with one or more risk factors for MDR organisms should be considered for similar treatment. HCAAP with one or more risk factors for MDR organisms or PA, plus septic shock, need for ICU admission or mechanical ventilation should receive double coverage for PA in addition to coverage for MRSA and anaerobes. Multiple gaps in current understanding and management of aspiration pneumonia require future research, with a particular focus on antibiotic stewardship.