Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19.

BACKGROUND: The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs). OBJECTIVE: To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19. DESIGN: Retrospective cohort. SETTING: Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN). TARGET POPULATION: Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020. MEASUREMENTS: We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs. RESULTS: Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error. LIMITATIONS: Results are limited by available documentation and do not capture communication between providers and patients. CONCLUSION: Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.

Assessing Perspectives on Systemic Racism in an Academic Hospital Medical Group: The ARCH Project.

BACKGROUND: Wisconsin residents experience significant racial inequities in health outcomes. OBJECTIVES: The University of Wisconsin School of Medicine and Public Health Division of Hospital Medicine wanted to assess providers' perspectives on systemic racism and gauge their receptiveness to participating in anti-racism training, in conjunction with development and implementation of anti-racism curriculum. METHODS: Existing anti-racism curriculum was adapted to be delivered remotely. Division providers were asked to complete a 9-question survey at the beginning of the curriculum. RESULTS: At baseline, a majority of respondents believed that racial health disparities exist and should be discussed through employer-sponsored training. Respondents generally did not feel confident in their abilities to address racism. CONCLUSIONS: Providers were supportive of anti-racism training in the workplace and feel it is congruent with the public health mission of hospital medicine physicians.

Are Antimotility Agents Safe for Use in Clostridioides difficile Infections? Results From an Observational Study in Malignant Hematology Patients.

OBJECTIVES: To evaluate the safety of antimotility agents (AAs) in a population of patients with hematologic malignancies and concurrent Clostridioides difficile infection (CDI) and to describe the outcomes of AA use in a hospital setting. PATIENTS AND METHODS: We used the electronic health record to identify patients who were hospitalized in the adult malignant hematology service who had 1 or more toxin-positive C difficile stool assay between April 1, 2012, and September 21, 2017. We reviewed medical charts to obtain information on the use of AAs and any subsequent gastrointestinal complications. RESULTS: There were 339 patients who were stool toxin positive for CDI during the study period. Of those, 94 patients (27%) were prescribed AAs within 14 days of CDI diagnosis. All patients received CDI antimicrobial therapy within the first 24 hours. There were 2 adverse gastrointestinal events in the group that received AAs and 6 in the group that did not receive AAs. The risk of adverse events did not differ between patients who received AAs and those who did not (adjusted odds ratio, 0.36; 95% CI, 0.06 to 2.10). The mean age of the full cohort was 52.7±15.5 years, and the mean length of stay was 26.7±22.6 days. Early AA use (<48 hours of diagnosis) was not associated with increased adverse effects. CONCLUSION: There was no increase in the incidence of gastrointestinal events in the arm that used AAs compared with the control arm. The evidence suggests that for patients with hematologic malignancies and CDI, the addition of AAs to appropriate antimicrobial therapy poses no additional risk.

COVID-19 coagulopathy and thrombosis: Analysis of hospital protocols in response to the rapidly evolving pandemic.

As the Coronavirus disease 2019 (COVID-19) pandemic spread to the US, so too did descriptions of an associated coagulopathy and thrombotic complications. Hospitals created institutional protocols for inpatient management of COVID-19 coagulopathy and thrombosis in response to this developing data. We collected and analyzed protocols from 21 US academic medical centers developed between January and May 2020. We found greatest consensus on recommendations for heparin-based pharmacologic venous thromboembolism (VTE) prophylaxis in COVID-19 patients without contraindications. Protocols differed regarding incorporation of D-dimer tests, dosing of VTE prophylaxis, indications for post-discharge pharmacologic VTE prophylaxis, how to evaluate for VTE, and the use of empiric therapeutic anticoagulation. These findings support ongoing efforts to establish international, evidence-based guidelines.

Pediatric Blood Management Protocol in Cranial Vault Surgery.

BACKGROUND: Cranial vault surgeries are invasive, extensive procedures with blood transfusions being frequently required. Previous interventions have been described to attempt to decrease the transfusion burden. The objective of this study is to determine if a Pediatric Blood Management (PBM) team can reduce transfusion requirements in children undergoing cranial vault surgery. METHODS: A protocol was developed which involved preoperative optimization of hemoglobin (Hb), intraoperative use of tranexamic acid, cell saver technology, and blood sparing operative techniques. Patients were preoperatively screened with basic laboratory testing. Retrospective data on 20 consecutive patients who underwent craniofacial surgery prior were used as controls. Prospective data on patients was collected. RESULTS: Groups were similar in age and weight. Postoperative Hb measurements were similar, with the control group 10.9 ±â€Š2.2 g/dL and the intervention arm 9.6 + 2.7 g/dL. Discharge Hb concentrations also were similar with 9.6 ±â€Š1.6 g/dL and 9.7 ±â€Š2.5 g/dL in the control and PBM group, respectively. The rate of transfusion decreased from 80% to 42% after protocol implementation (P = 0.007). During the last 6 months of data collection, the transfusion rate decreased further to 17%. Furthermore, 4 patients were found to have von Willebrand disease preoperatively with only 1 requiring a transfusion. CONCLUSIONS: The authors found that the institution of a PBM team reduced the transfusion burden of patients, including complex patients with von Willebrand disease. The use of a multimodal approach to hematologic management optimized patients for their procedures and helped minimize exposure to transfusion associated complications.

Intravenous Ferumoxytol in Pediatric Patients With Iron Deficiency Anemia.

BACKGROUND: Iron deficiency anemia (IDA) is common in children. Limited data exist on the efficacy and safety of ferumoxytol in children. OBJECTIVE: To assess the efficacy of 10 mg/kg dose given over 15-60 minutes in correcting IDA and report any adverse drug reactions (ADRs). METHODS: We conducted a retrospective review of all patients who received ferumoxytol infusions for the management of IDA by the Pediatric Blood Management Program between October 2010 and March 2015. RESULTS: A total of 110 infusions were given to 54 patients. Compared with baseline preinfusion hemoglobin (Hb; 9.2 ± 1.9 g/dL), a significant rise was seen at 1 week and 4 weeks postinfusion (11.5 ± 1.5 and 11.8 ± 1.7 g/dL, respectively, P < 0.001). Also, a significant rise in serum ferritin at 1 week and 4 weeks postinfusion was seen (51 ± 71 vs 192 ± 148 and 89 ± 135 ng/mL, P < 0.001 and <0.035, respectively). Patients who concomitantly received erythropoietin had a significantly larger Hb rise from baseline than those who did not at 4 weeks (2.7 ± 2.2 vs 1.6 ± 1.1 g/dL, P < 0.017). ADRs included pruritus (n = 1), urticaria (n = 1), and multisymptom episodes (n = 3) that included shortness of breath, chest tightness, back pain, and epigastric cramping that responded to therapy with IV diphenhydramine and methylprednisolone. CONCLUSION: Ferumoxytol was effective in treating IDA in our small study. Slow infusion rate and close monitoring allowed early detection of the infrequent ADRs.

Multiplexed detection of viral infections using rapid in situ RNA analysis on a chip.

Viral infections are a major cause of human disease, but many require molecular assays for conclusive diagnosis. Current assays typically rely on RT-PCR or ELISA; however, these tests often have limited speed, sensitivity or specificity. Here, we demonstrate that rapid RNA FISH is a viable alternative method that could improve upon these limitations. We describe a platform beginning with software to generate RNA FISH probes both for distinguishing related strains of virus (even those different by a single base) and for capturing large numbers of strains simultaneously. Next, we present a simple fluidic device for reliably performing RNA FISH assays in an automated fashion. Finally, we describe an automated image processing pipeline to robustly identify uninfected and infected samples. Together, our results establish RNA FISH as a methodology with potential for viral point-of-care diagnostics.

Become the PPUPET Master: Mastering Pressure Ulcer Risk Assessment With the Pediatric Pressure Ulcer Prediction and Evaluation Tool (PPUPET).

Hospital acquired pressure ulcers (HAPU) are serious, debilitating, and preventable complications in all inpatient populations. Despite evidence of the development of pressure ulcers in the pediatric population, minimal research has been done. Based on observations gathered during quarterly HAPU audits, bedside nursing staff recognized trends in pressure ulcer locations that were not captured using current pressure ulcer risk assessment tools. Together, bedside nurses and nursing leadership created and conducted multiple research studies to investigate the validity and reliability of the Pediatric Pressure Ulcer Prediction and Evaluation Tool (PPUPET).

Gene profiling of the rat medial collateral ligament during early healing using microarray analysis.

Ligament heals in a synchronized and complex series of events. The remodeling process may last months or years. Experimental evidence suggests the damaged ligament does not recover its normal functional properties. Specific mechanisms to prevent scar formation and to regenerate the original mechanical function remain elusive but likely involve regulation of creeping substitution. Creeping substitution creates a larger hypercellular, hypervascular, and disorganized granulation tissue mass that results in an inefficient and nonregenerative wound healing process for the ligament. Control of creeping substitution may limit the extent of this tissue compromise and reduce the time necessary for healing. The objective of this study is to better understand the mechanism behind scar formation by identifying the extracellular matrix factors and other unique genes of interest differentially expressed during rat ligament healing via microarray. For this study, rat medial collateral ligaments were either surgically transected or left intact. Ligaments were collected at day 3 or 7 postinjury and used for microarray, quantitative PCR, and/or immunohistochemistry. Results were compared with the normal intact ligament. We demonstrate that early ligament healing is characterized by the modulation of several inflammatory and extracellular matrix factors during the first week of injury. Specifically, a number of matrix metalloproteinases and collagens are differentially and significantly expressed during early ligament healing. Additionally, we demonstrate the modulation of three novel genes, periostin, collagen-triple helix repeat containing-1, and serine protease 35 in our ligament healing model. Together, control of granulation tissue creeping substitution and subsequent downstream scar formation is likely to involve these factors.

Metabolic activity of osteoarthritic knees correlates with BMI.

Osteoarthritis of the knee has consistently been linked to obesity, defined as a body mass index (BMI) >30kg/m(2). It has been hypothesized that obesity may lead to osteoarthritis through increased joint pressure, accumulated microtrauma, and disruption of normal chondrocyte metabolism. These changes in chondrocyte metabolism have not been thoroughly investigated, and it is the purpose of this study to identify a relationship between BMI and altered chondrocyte metabolism in osteoarthritic tissue. Articular cartilage was harvested from the femoral condyles of patients after total knee arthroplasty, and analyzed in explant and alginate models. Glycosaminoglycan (GAG) content was measured using a dimethylmethylene blue assay and normalized to DNA content using a PicoGreen(R) assay. Studies have reported GAGs to be a reliable measurement of chondrocyte metabolism and osteoarthritis progression. Our results show a significant linear relationship of increasing BMI and increasing GAG content in both alginate and explant models (p<0.001 and p=0.001). Obese (BMI>/=30kg/m(2)) and non-obese (BMI<30kg/m(2)) comparisons also demonstrated significant differences with higher GAG/DNA content in obese individuals compared to non-obese (p=0.001 and p=0.015). The study results reveal significant relationships between GAG content and BMI in this population of osteoarthritic patients. The significant difference in GAG content between the obese and non-obese patients supports the connection between osteoarthritis and obesity previously reported. Higher patient BMI (>30kg/m(2)) may be similar to dynamic compression injuries which cause increased GAG synthesis in response to cartilage damage.

New insights into HIV resistance testing: nursing guidelines and implications.

The detection of resistance by HIV drug resistance assays has become an important management tool for use in the HIV-infected patient. Because of its important role in management of HIV disease, it is important for the nurse to understand the mechanism of HIV resistance, the appropriate use of resistance tests, and how to use this information to improve or maximize patient outcomes. The purpose of this review is to increase the nurse's awareness of the problem of resistance, to describe the available resistance tests, and to develop a model whereby the patient collaborates with the health care team in understanding, implementing, and monitoring resistance-related actions.

Multidisciplinary care of the dying adolescent.

The adolescent at the end of life poses a unique combination of challenges resulting from the collision of failing health with a developmental trajectory meant to lead to attainment of personal independence. Because virtually all spheres of the dying adolescent's life are affected, optimal palliative care for these young persons requires a multidisciplinary team whose members have a good understanding of their complementary roles and a shared commitment to providing well-coordinated care. Members of the team include the physician (to initiate and coordinate palliative care management); the nurse (to work collaboratively with the physician and adolescent, especially through effective patient advocacy); the psychologist (to assess and manage the patient's neurocognitive and emotional status); the social worker (to assess and optimize support networks); the chaplain (to support the adolescent's search for spiritual meaning); and the child life specialist (to facilitate effective communication in preparing for death). A crucial area for dying adolescents is medical decision making, where the full range of combined support is needed. By helping the young person continue to develop personal autonomy, the multidisciplinary team will enable even the dying adolescent to experience dignity and personal fulfillment.

Treatment of anemia in patients with HIV Infection--Part 2: guidelines for management of anemia.

The key treatment goal for managing anemia in patients infected with HIV is to maintain an improved or normal hemoglobin level. Whenever possible, the identification and treatment of the underlying cause of anemia is the primary therapeutic strategy. After excluding other etiologies, the Nursing Guidelines Committee for Anemia in Patients With HIV Infection has recommended that patients with mild asymptomatic anemia (hemoglobin level = 1 g/dl below the lower limit of the normal range) receive nutritional support and more frequent screening. Recombinant human erythropoietin (epoetin alfa) therapy is an appropriate treatment option for patients with symptomatic mild anemia or moderate anemia (hemoglobin level = 2 g/dl below the lower limit of the normal range). An immediate blood transfusion may be required under specific instances for patients with severe anemia (hemoglobin level less than or equal to 8 g/dl).