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BACKGROUND: Hispanic and Latino patients are under-represented in existing healthcare disparities research in pulmonary embolism (PE). The goal of this study was to determine if differences in PE severity, treatment modality, or in-hospital outcomes exist for Hispanic or Latino patients with PE. METHODS: All PE cases from 2013 to 2019 at a single institution were reviewed. Clinical characteristics, imaging findings, intervention types, and in-hospital and 30-day outcomes were collected. Two cohorts were created based on patients' self-reported ethnicity. Outcomes were compared using univariate and multivariate analysis. RESULTS: A total of 1265 patients were identified with confirmed PE; 474 (37%) identified as Hispanic or Latino. Hispanic or Latino patients presented with high-risk PE significantly less often (19% vs 25%, p = 0.03). On univariate analysis, Hispanic or Latino patients had lower rates of PE-specific intervention (15% vs 19%, p = 0.03) and similar rates of inpatient mortality (6.8% vs 7.5%, p = 0.64). On ordinal regression analysis, Hispanic or Latino ethnicity was associated with lower PE severity (OR 0.69, 95% CI 0.54-0.89, p = 0.003). In subgroup analyses of intermediate and high-risk PEs, ethnicity was not a significant predictor of receipt of PE-specific intervention or in-hospital mortality. CONCLUSIONS: At this institution, Hispanic or Latino patients were less likely to present with high-risk PE but had similar rates of inpatient mortality. Future research is needed to identify if disparities in in-hospital care are driving perceived differences in PE severity and what addressable systematic factors are driving higher-than-expected in-hospital mortality for Hispanic or Latino patients.
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Hispánicos o Latinos , Embolia Pulmonar , Humanos , Hospitales , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/terapiaRESUMEN
Cardiac involvement associated with multi-system inflammatory syndrome in children has been extensively reported, but the prevalence of cardiac involvement in children with SARS-CoV-2 infection in the absence of inflammatory syndrome has not been well described. In this retrospective, single centre, cohort study, we describe the cardiac involvement found in this population and report on outcomes of patients with and without elevated cardiac biomarkers. Those with multi-system inflammatory syndrome in children, cardiomyopathy, or complex CHD were excluded. Inclusion criteriaz were met by 80 patients during the initial peak of the pandemic at our institution. High-sensitivity troponin T and/or N-terminal pro-brain type natriuretic peptide were measured in 27/80 (34%) patients and abnormalities were present in 5/27 (19%), all of whom had underlying comorbidities. Advanced respiratory support was required in all patients with elevated cardiac biomarkers. Electrocardiographic abnormalities were identified in 14/38 (37%) studies. Echocardiograms were performed on 7/80 patients, and none demonstrated left ventricular dysfunction. Larger studies to determine the true extent of cardiac involvement in children with COVID-19 would be useful to guide recommendations for standard workup and management.
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COVID-19 , Humanos , Niño , Adolescente , COVID-19/epidemiología , Estudios Retrospectivos , SARS-CoV-2 , Estudios de Cohortes , Biomarcadores , Péptido Natriurético EncefálicoRESUMEN
IMPORTANCE: Hospitals that serve poorer populations have higher readmission rates. It is unknown whether these hospitals effectively lowered readmission rates in response to the Hospital Readmissions Reduction Program (HRRP). OBJECTIVE: To compare pre-post differences in readmission rates among hospitals with different proportion of dual-eligible patients both generally and among the most highly penalized (ie, low performing) hospitals. DESIGN: Retrospective cohort study using piecewise linear model with estimated hospital-level risk-standardized readmission rates (RSRRs) as the dependent variable and a change point at HRRP passage (2010). Economic burden was assessed by proportion of dual-eligibles served. SETTING: Acute care hospitals within the United States. PARTICIPANTS: Medicare fee-for-service beneficiaries aged 65 years or older discharged alive from January 1, 2003 to November 30, 2014 with a principal discharge diagnosis of acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. MAIN OUTCOME AND MEASURE: Decrease in hospital-level RSRRs in the post-law period, after controlling for the pre-law trend. RESULTS: For AMI, the pre-post difference between hospitals that service high and low proportion of dual-eligibles was not significant (-65 vs. -64 risk-standardized readmissions per 10000 discharges per year, P=0.0678). For CHF, RSRRs declined more at high than low dual-eligible hospitals (-79 vs. -75 risk-standardized readmissions per 10000 discharges per year, P=0.0006). For pneumonia, RSRRs declined less at high than low dual-eligible hospitals (-44 vs. -47 risk-standardized readmissions per 10000 discharges per year, P=0.0003). Among the 742 highest penalized hospitals and all conditions, the pre-post decline in rate of change of RSRRs was less for high dual-eligible hospitals than low dual-eligible hospitals (-68 vs. -74 risk-standardized readmissions per 10000 discharges per year for AMI, -88 vs. -97 for CHF, and -47 vs. -56 for pneumonia, P<0.0001 for all). CONCLUSIONS AND RELEVANCE: For all hospitals, differences in pre-post trends in RSRRs varied with disease conditions. However, for the highest-penalized hospitals, the pre-post decline in RSRRs was greater for low than high dual-eligible hospitals for all penalized conditions. These results suggest that high penalty, high dual-eligible hospitals may be less able to improve performance on readmission metrics.
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Medicaid/estadística & datos numéricos , Medicare/legislación & jurisprudencia , Readmisión del Paciente/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Comorbilidad , Planes de Aranceles por Servicios , Femenino , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/terapia , Humanos , Masculino , Infarto del Miocardio/epidemiología , Infarto del Miocardio/terapia , Propiedad , Neumonía/epidemiología , Neumonía/terapia , Pobreza , Características de la Residencia , Estudios Retrospectivos , Estados UnidosRESUMEN
Background Disaster triage training equips learners with the critical skills to rapidly evaluate patients, yet few medical schools include formal triage training in their curriculum. Simulation exercises can successfully teach triage skills, but few studies have specifically evaluated online simulation to teach these skills to medical students. Aims We sought to develop and evaluate a largely asynchronous activity for senior medical students to practice their triage skills in an online format. Methods We developed an online, interactive triage exercise for fourth-year medical students. For the exercise, the student participants acted as triage officers for an emergency department (ED) at a large tertiary care center during an outbreak of a severe respiratory illness. Following the exercise, a faculty member led a debriefing session using a structured debriefing guide. Pre- and post-test educational assessments used a five-point Likert scale to capture the helpfulness of the exercise and their self-reported pre- and post-competency in triage. Change in self-reported competency was analyzed for statistical significance and effect size. Results Since May 2021, 33 senior medical students have completed this simulation and pre- and post-test educational assessments. Most students found the exercise "very" or "extremely" helpful for learning, with a mean of 4.61 (SD: ±0.67). Most students rated their pre-exercise competency as "beginner" or "developing" and their post-exercise competency as "developing" or "proficient" on a four-point rubric. The average increase in self-reported competency was 1.17 points (SD: ±0.62), yielding a statistically significant difference (p < 0.001) and large effect size (Hedges' g: 1.94). Conclusions We conclude that a virtual simulation can increase students' sense of competence in triage skills, using fewer resources than in-person simulation of disaster triage. As a next step, the simulation and the source code are publicly available for anyone to engage with the simulation or adapt it for their respective learners.
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BACKGROUND: In the IMAGEstudy, rituximab plus methotrexate (MTX) inhibited joint damage and improved clinical outcomes at 1 year in MTX-naïve patients with early active rheumatoid arthritis. OBJECTIVE: The aim of this study was to assess joint damage progression and clinical outcomes over 2 years. METHODS: Patients (n=755) were randomised to receive rituximab 2×500 mg+MTX, 2×1000 mg+MTX or placebo+MTX. The placebo-controlled period continued to week 104. Two-year end points were defined as secondary or exploratory and included change in total Genant-modified Sharp score (mTSS), total erosion score and joint space narrowing score from baseline to week 104. Clinical efficacy and physical function end points were also assessed. RESULTS: At 2 years, rituximab 2×1000 mg+MTX maintained inhibition of progressive joint damage versus MTX alone (mTSS change 0.41 vs 1.95; p<0.0001 (79% inhibition)), and a higher proportion of patients receiving rituximab 2×1000 mg+MTX had no radiographic progression over 2 years compared with those receiving MTX alone (57% vs 37%; p<0.0001). Contrary to 1-year results, exploratory analysis of rituximab 2×500 mg+MTX at 2 years showed that progressive joint damage was slowed by â¼61% versus placebo+MTX (mTSS, exploratory p=0.0041). Improvements in clinical signs and symptoms and physical function seen after 1 year in rituximab-treated patients versus those receiving placebo were maintained at year 2. Safety profiles were similar between groups. CONCLUSIONS: Treatment with rituximab 2×1000 mg+MTX was associated with sustained improvements in radiographic, clinical and functional outcomes over 2 years. Clinical trials.gov identifier NCT00299104.
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Anticuerpos Monoclonales de Origen Murino/administración & dosificación , Antirreumáticos/administración & dosificación , Artritis Reumatoide/tratamiento farmacológico , Metotrexato/administración & dosificación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anticuerpos Monoclonales de Origen Murino/efectos adversos , Antirreumáticos/efectos adversos , Artritis Reumatoide/diagnóstico por imagen , Artritis Reumatoide/fisiopatología , Progresión de la Enfermedad , Relación Dosis-Respuesta a Droga , Quimioterapia Combinada , Estudios de Seguimiento , Humanos , Metotrexato/efectos adversos , Persona de Mediana Edad , Radiografía , Recuperación de la Función , Rituximab , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Adulto JovenRESUMEN
Context: Retrospective study of 36 individuals with sickle cell disease (SCD) certified for medical cannabis. Objective: We sought to examine whether medical cannabis certification was associated with a change in utilization of acute care medical services for patients with SCD. Methods: We identified patients with SCD certified for medical cannabis use between July 2014 and December 2021 using the New York State Prescription Monitoring Program (NYS PMP) and cross-matching to our electronic medical record. We estimated the mean incidences of Emergency Department (ED) visits, hospital admissions, inpatient days, and total acute encounters for SCD-related pain per month pre- and post-medical cannabis certification and used paired t-tests to assess the statistical significance of changes in hospital use. We stratified incidence based on whether patients had received a bone marrow transplant (BMT) at any point before or during the research period, since BMT is potentially an important covariate. Recertification rates and patients' reasons for choosing to recertify were qualitatively investigated through retrospective chart review. Results: The incidence of ED visits, hospital admissions, and total acute encounters per month for SCD-related pain decreased pre- to post-certification (p=0.02; p=0.02; p=0.01). These decreases lost statistical significance after stratifying patients based on BMT history. There was no statistically significant change in the number of days per month patients spent hospitalized in either the primary analysis or after stratification by BMT status. Forty-four percent of patients chose to be recertified. Thirty-six percent of patients cited concerns regarding the cost of medical cannabis. Conclusion: Our study did not show a statistically significant relationship between certification for medical cannabis and hospital use after addressing BMT history as a potentially important covariate. However, we were likely underpowered to detect any existing difference after patient data were stratified due to our small sample size. Regardless, 44% of patients chose to be recertified, indicating a perceived benefit and utility in further investigation of medical cannabis for this population with a larger analytic sample. Patient-reported benefits were improvement of pain and other symptoms, decreased opiate requirements, and decreased side effects compared to opiates.
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BACKGROUND: The interval between inpatient hospitalization for symptomatic coronary artery disease (CAD) and post-discharge office consultation is a vulnerable period for adverse events. METHODS: Content was customized on a smartphone app-based platform for hospitalized patients receiving percutaneous coronary intervention (PCI) which included education, tracking, reminders and live health coaches. We conducted a single-arm open-label pilot study of the app at two academic medical centers in a single health system, with subjects enrolled 02/2018-05/2019 and 1:3 propensity-matched historical controls from 01/2015-12/2017. To evaluate feasibility and efficacy, we assessed 30-day hospital readmission (primary), outpatient cardiovascular follow-up, and cardiac rehabilitation (CR) enrollment as recorded in the health system. Outcomes were assessed by Cox Proportional Hazards model. FINDINGS: 118 of 324 eligible (36·4%) 21-85 year-old patients who underwent PCI for symptomatic CAD who owned a smartphone or tablet enrolled. Mean age was 62.5 (9·7) years, 87 (73·7%) were male, 40 of 118 (33·9%) had type 2 diabetes mellitus, 68 (57·6%) enrolled underwent PCI for MI and 59 (50·0%) had previously known CAD; demographics were similar among matched historical controls. No significant difference existed in all-cause readmission within 30 days (8·5% app vs 9·6% control, ARR -1.1% absolute difference, 95% CI -7·1-4·8, p = 0·699) or 90 days (16·1% app vs 19·5% control, p = 0.394). Rates of both 90-day CR enrollment (HR 1·99, 95% CI 1·30-3·06) and 1-month cardiovascular follow up (HR 1·83, 95% CI 1·43-2·34) were greater with the app. Weekly engagement at 30- and 90-days, as measured by percentage of weeks with at least one day of completion of tasks, was mean (SD) 73·5% (33·9%) and 63·5% (40·3%). Spearman correlation analyses indicated similar engagement across age, sex, and cardiovascular risk factors. INTERPRETATIONS: A post-PCI smartphone app with live health coaches yielded similarly high engagement across demographics and safely increased attendance in cardiac rehabilitation. Larger prospective randomized controlled trials are necessary to test whether this app improves cardiovascular outcomes following PCI. FUNDING: National Institutes of Health, Boston Scientific. CLINICAL TRIAL REGISTRATION: NCT03416920 (https://clinicaltrials.gov/ct2/show/NCT03416920).
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Enfermedad de la Arteria Coronaria/terapia , Tutoría/métodos , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/métodos , Adulto , Anciano , Anciano de 80 o más Años , Diabetes Mellitus Tipo 2/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Aplicaciones Móviles , Alta del Paciente , Proyectos Piloto , Teléfono InteligenteRESUMEN
BACKGROUND: In the U.S. presidential election of 2016, communities with poorer public health shifted votes to the Republican party. Whether this trend has persisted beyond 2016 is unclear. METHODS: We created a county-level measure of public health (the "unhealthy" component) by performing principal component analysis on 9 health statistics. We then estimated shifting of votes by defining "net vote shift" as the percentage of Republican votes in the 2018 U.S. House of Representatives election minus the percentage of Republican votes in the same election in 2016. Finally, we performed linear regression to assess the independent, county-level association of the unhealthy component with net vote shift after adjusting for county-level demographic factors. RESULTS: The mean county-level net vote shift was -6.4 percentage points (SD 12.6 percentage points), consistent with a mean net vote shift toward the Democratic party. After adjustment for demographic covariates, the unhealthy score was associated with higher net vote shift (17.7 percentage points shift toward Republican per unit unhealthy, p = .0323). CONCLUSIONS: In the 2018 congressional elections, despite an overall shift toward the Democratic Party there is evidence of ongoing shifting of community voting in unhealthy communities toward the Republican party.
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Política , Salud Pública , Humanos , Estados UnidosRESUMEN
OBJECTIVES: This study sought to assess medical management of patients found to have nonobstructive coronary artery disease (CAD) on coronary computed tomography angiography (CCTA) performed in the emergency department (ED). BACKGROUND: Contemporary recognition and management of nonobstructive CAD discovered on CCTA performed in the ED is unknown. METHODS: Patients undergoing CCTA in the authors' hospital's ED between November 2013 and March 2018 who also received primary care within the authors' health system were studied. All patients with nonobstructive CAD, defined as 1% to 49% maximum luminal stenosis on CCTA, were included, along with a control group without CAD in a 1 case:1 control fashion. Ten-year atherosclerotic cardiovascular disease (ASCVD) risk prior to CCTA was estimated using the Pooled Cohort Equations. Management changes were recorded until 6 months after CCTA. Multivariate logistic regression tested the association between CCTA result and follow-up statin prescription, adjusting for cardiovascular risk factors and baseline statin use. RESULTS: The cohort included 510 patients with nonobstructive CAD and 510 controls. Prevalence of statin prescription increased from 38.8% to 56.1% among patients with nonobstructive CAD (p < 0.001) and 18.0% to 20.4% among controls (p = 0.01), representing a 7.1-fold relative difference (95% confidence interval [CI]: 4.4 to 23.0; p < 0.001) in multivariate analysis. However, 30.0% of patients with nonobstructive CAD and ≥20% 10-year ASCVD risk were not prescribed a statin at the end of follow-up. Cardiologist evaluation was independently associated with statin prescription after adjustment for ASCVD risk factors (odds ratio [OR] 4.4; 95% CI: 2.4 to 8.5; p < 0.001). A Coronary Artery Disease Reporting and Data System class 1 to 2 result was associated with lower low-density lipoprotein cholesterol by 12.1 mg/dl at mean 1.9-year follow-up (p < 0.001). CONCLUSIONS: Incidental subclinical atherosclerosis on CCTA performed in the ED increases the likelihood of statin prescription, but opportunities to improve allocation of indicated preventive therapies remain.
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Servicio de Cardiología en Hospital , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Servicio de Urgencia en Hospital , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Tomografía Computarizada Multidetector , Prevención Primaria , Adulto , Anciano , Enfermedades Asintomáticas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: Patients with isolated tricuspid regurgitation (TR) in the absence of left-sided valvular dysfunction are often managed nonoperatively. OBJECTIVES: The purpose of this study was to assess the impact of surgery for isolated TR, comparing survival for isolated severe TR patients who underwent surgery with those who did not. METHODS: A longitudinal echocardiography database was used to perform a retrospective analysis of 3,276 adult patients with isolated severe TR from November 2001 to March 2016. All-cause mortality for patients who underwent surgery versus those who did not was analyzed in the entire cohort and in a propensity-matched sample. To assess the possibility of immortal time bias, the analysis was performed considering time from diagnosis to surgery as a time-dependent covariate. RESULTS: Of 3,276 patients with isolated severe TR, 171 (5%) underwent tricuspid valve surgery, including 143 (84%) repairs and 28 (16%) replacements. The remaining 3,105 (95%) patients were medically managed. When considering surgery as a time-dependent covariate in a propensity-matched sample, there was no difference in overall survival between patients who received medical versus surgical therapy (hazard ratio: 1.34; 95% confidence interval: 0.78 to 2.30; p = 0.288). In the subgroup that underwent surgery, there was no difference in survival between tricuspid repair versus replacement (hazard ratio: 1.53; 95% confidence interval: 0.74 to 3.17; p = 0.254). CONCLUSIONS: In patients with isolated severe TR, surgery is not associated with improved long-term survival compared to medical management alone after accounting for immortal time bias.