Universal SARS-CoV-2 Testing of Emergency Department Admissions Increases Emergency Department Length of Stay.

STUDY OBJECTIVE: Our institution experienced a change in SARS-CoV-2 testing policy as well as substantial changes in local COVID-19 prevalence, allowing for a unique examination of the relationship between SARS-CoV-2 testing and emergency department (ED) length of stay. METHODS: This was an observational interrupted time series of all patients admitted to an academic health system between March 15, 2020, and September 30, 2020. Given testing limitations from March 15 to April 24, all patients receiving SARS-CoV-2 tests were symptomatic. On April 24, testing was expanded to all ED admissions. The primary and secondary outcomes were ED length of stay and number needed to test to obtain a positive, respectively. RESULTS: A total of 70,856 patients were cared for in the EDs during the 7-month period. The testing change increased admission length of stay by 1.89 hours (95% confidence interval 1.39 to 2.38). The number needed to test was 2.5 patients and was highest yield on April 1, 2020, when the state positivity rate was 39.7%; however, the number needed to test exceeded 170 patients by Sept 1, 2020, at which point the state positivity rate was 0.5%. CONCLUSION: Although universal SARS-CoV-2 testing of ED admissions may meaningfully support mitigation and containment efforts, the clinical cost of testing all admissions amid low community positivity is notable. In our system, universal ED SARS-CoV-2 testing was associated with a 24% increase in admission length of stay alongside the detection of only 1 positive case every other day. Given the known harms and risks of ED boarding and crowding, solutions must be developed to support regular operational flow while balancing infection prevention needs.

Aligning mission to digital health strategy in academic medical centers.

The strategies of academic medical centers arise from core values and missions that aim to provide unmatched clinical care, patient experience, research, education, and training. These missions drive nearly all activities. They should also drive digital health activities - and particularly now given the rapid adoption of digital health, marking one of the great transformations of healthcare; increasing pressures on health systems to provide more cost-effective care; the pandemic-accelerated funding and rise of well-funded new entrants and technology giants that provide more convenient forms of care; and a more favorable regulatory and reimbursement landscape to incorporate digital health approaches. As academic medical centers emerge from a pandemic-related reactionary digital health posture, where pressures to adopt more digital health technologies mount, a broad digital health realignment that leverages the strengths of such centers is required to accomplish their missions.

Real-world assessment of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) nasopharyngeal swab testing in a region with a high burden of coronavirus disease 2019 (COVID-19).

Concerns persist regarding possible false-negative results that may compromise COVID-19 containment. Although obtaining a true false-negative rate is infeasible, using real-life observations, the data suggest a possible false-negative rate of ˜2.3%. Use of a sensitive, amplified RNA platform should reassure healthcare systems.

Mass severe acute respiratory coronavirus 2 (SARS-CoV-2) testing of asymptomatic healthcare personnel.

Mass asymptomatic SARS-CoV-2 nucleic acid amplified testing of healthcare personnel (HCP) was performed at a large tertiary health system. A low period-prevalence of positive HCP was observed. Of those who tested positive, half had mild symptoms in retrospect. HCP with even mild symptoms should be isolated and tested.

Improving laboratory test utilisation at the multihospital Yale New Haven Health System.

BACKGROUND: Waste persists in healthcare and negatively impacts patients. Clinicians have direct control over test ordering and ongoing international efforts to improve test utilisation have identified multifaceted approaches as critical to the success of interventions. Prior to 2015, Yale New Haven Health lacked a coherent strategy for laboratory test utilisation management. METHODS: In 2015, a system-wide laboratory formulary committee was formed at Yale New Haven Health to manage multiple interventions designed to improve test utilisation. We report here on specific interventions conducted between 2015 and 2017 including reduction of (1) obsolete or misused testing, (2) duplicate orders, and (3) daily routine lab testing. These interventions were driven by a combination of modifications to computerised physician order entry, test utilisation dashboards and physician education. Measurements included test order volume, blood savings and cost savings. RESULTS: Testing for a number of obsolete/misused analytes was eliminated or significantly decreased depending on alert rule at order entry. Hard stops significantly decreased duplicate testing and educational sessions significantly decreased daily orders of routine labs and increased blood savings but the impact waned over time for select groups. In total, we realised approximately $100 000 of cost savings during the study period. CONCLUSION: Through a multifaceted approach to utilisation management, we show significant reductions in low-value clinical testing that have led to modest but significant savings in both costs and patients' blood.

Using System Inflammatory Response Syndrome as an Easy-to-Implement, Sustainable, and Automated Tool for All-Cause Deterioration Among Medical Inpatients.

OBJECTIVES: Clinical deterioration detection among adult inpatients is known to be suboptimal, and many electronic health record tools have been developed to help identify these patients. Many of these tools are focused on sepsis spectrum disorders, but the evolution of the definition of sepsis is moving toward increased specificity, which may make automated detection of clinical deterioration from nonsepsis-related conditions less likely. The objectives of this study were to develop and to examine the use of a low-cost, highly sustainable deterioration detection tool based on systemic inflammatory response syndrome (SIRS) criteria. METHODS: Using existing resources, a SIRS-based electronic health record monitoring and intervention tool was developed with a focus on ease of implementation and high sustainability. This tool was used to monitor 15,739 adult inpatients in real time during their admission. RESULTS: The SIRS-based tool, created with focus on ease of implementation and high sustainability, identified patients with higher risk of clinical deterioration. The project was rapidly deployed for a 4-month period at a 900-bed campus of an academic medical center with minimal additional resources required. CONCLUSIONS: Whereas the definition of sepsis moves away from SIRS, SIRS-based criteria may still have clinical benefit as an easy-to-automate detection tool for all-cause clinical deterioration among medical inpatients.

Eliminating Inappropriate Telemetry Monitoring: An Evidence-Based Implementation Guide.

In-hospital continuous electrocardiographic monitoring, commonly referred to as telemetry, has allowed for rapid recognition of life-threatening conditions, including complex arrhythmias and myocardial ischemia. However, inappropriate use can lead to unnecessary downstream testing from "false alarms," which in turn affects clinician efficiency and increases health care costs without benefiting patients. For these reasons, the Society of Hospital Medicine's Choosing Wisely campaign recommended use of a protocol-driven discontinuation of telemetry. The American Heart Association (AHA) developed a set of Practice Standards for the appropriate use of telemetry monitoring in 2004, which they updated in 2017. Unfortunately, the AHA Practice Standards have not been widely adopted-with as many as 43% of monitored patients lacking a recommended indication for monitoring. Thus, we created an overview discussing the safety and efficacy of incorporating the AHA Practice Standards and a review of studies highlighting their successful incorporation within patient care workflow. We conclude by outlining an "implementation blueprint" for health system professionals and administrators seeking to change their institution's culture of telemetry use. As the health care landscape continues to shift, enacting high-value initiatives that improve patient safety and efficiency of care will be critical.

Willingness to participate in AIDS vaccine trials among high-risk populations in northern Thailand.

OBJECTIVES: To determine the anticipated participation in a prophylactic AIDS vaccine trial and to identify perceived benefits and barriers to enrollment of HIV-seronegative volunteers at risk of HIV infection in northern Thailand. DESIGN: A cross-sectional survey. METHODS: Subjects interviewed in a cross-sectional survey included female commercial sex workers (n = 215), men attending sexually transmitted disease clinics (n = 219), conscripts in the Royal Thai Army (n = 1453), and men discharged from the army (n = 293) who had returned to civilian life. We determined AIDS vaccine knowledge and attitudes, perceived vulnerability to HIV infection, barriers and incentives to participate in a future vaccine trial and agreement to participate in a randomized trial. RESULTS: Awareness of vaccines (88-97%) and AIDS vaccine development efforts (62-77%) were common and viewed to be a complement to behavior change (74-94%). Approximately 25% of subjects would definitely join a trial if asked, and an additional 38% would accept an AIDS vaccine if they were convinced it would be safe and effective. Important barriers to participation included concerns with discrimination (16-45%), short- (37-60%) and long-term (30-55%) vaccine side-effects, fear of disability and death (36-58%), and beliefs that partners would refuse to have sex (24-49%) after immunization. The principal inducement to join a trial was health insurance (62%). CONCLUSION: Potential HIV vaccine trial participants have several fears of joining a vaccine study at this time. Information derived from Phase I/II trials is needed to address these concerns if enrollment in efficacy trials is to be successful in the near future.

PIP: Thailand has been designated a site for preventive human immunodeficiency virus (HIV) vaccine trials, and Phase I and II trials are currently underway. To assess the feasibility of large-scale Phase III trials involving high-risk individuals, questionnaires were administered to four cohorts of potential participants from North Thailand: 215 female commercial sex workers recruited from sexually transmitted disease (STD) clinics, 219 male STD clients from the same area, 1453 men conscripted into the Royal Thai Army in 1993, and 293 men discharged from the Army in 1993. Approximately 25% of members of each cohort indicated they would definitely join a prophylactic acquired immunodeficiency syndrome (AIDS) trial. The major barriers to participation were concerns about vaccine safety (61% of military cohorts and 32% of civilians) and fear of acquiring AIDS through vaccination (21%). Also expressed were concerns about social discrimination, immediate side effects, and rejection by sexual partner. Two-thirds of respondents indicated that provision of a five-year family health insurance plan would induce them to participate in a vaccine trial, while another 25% did not require any incentive. Overall, these findings indicate that steps must be taken to alleviate fears and misconceptions associated with HIV vaccines before Phase III is initiated.

HIV-1 infection among lower class commercial sex workers in Chiang Mai, Thailand.

OBJECTIVE: To determine risk factors for HIV-1 infection in female commercial sex workers (CSW) in northern Thailand. METHODS: A cross-sectional survey of female CSW from 11 sex establishments frequented by military conscripts that included an interview and serological testing for HIV-1. RESULTS: The HIV-1 seroprevalence in 230 CSW was 65%; the rate was lower among CSW from Chiang Mai than from rural areas. Multivariate logistic regression analysis for HIV-1 included the following significant factors: non-urban location of the sex establishment, ethnic Thai lowlander, lower price, history of genital warts and dysuria. Condom use, number of partners and duration of employment were not significantly associated with HIV-1 prevalence after adjustment for other risk factors. CONCLUSIONS: The high level of HIV-1 seroprevalence in this sample demonstrates the risk of transmission in lower cost commercial sex encounters in northern Thailand. Non-Thais (ethnic Hill tribes and Burmese) had lower HIV-1 prevalence than ethnic Thais. Type of establishment ('direct' brothel-based or 'indirect' establishments) was not predictive of HIV-1 seroprevalence. However, rural establishments were less vigilant in promoting condom use, suggesting the need for renewed efforts to enforce the Ministry of Public Health's '100% Condom Campaign' in commercial sex establishments.

Prolonged postictal encephalopathy.

Eleven patients (6 males, 5 females; ages 7.5 to 40 years, mean 27.8) had prolonged postictal confusion lasting from 4 to 10 days. During that time, the EEG showed a typical encephalopathic pattern. Comprehensive evaluation ruled out the possibility of metabolic, toxic, drug-related, or ongoing nonconvulsive status epilepticus. We have designated this syndrome as prolonged postictal encephalopathy (PPIE). Nine of 11 patients were mildly to borderline mentally retarded. Ten had previous episodes of status epilepticus. Nine of 11 had minimal structural abnormalities (mainly diffuse cortical atrophy). Nine patients had multiple recurrent episodes of PPIE. All episodes occurred following a cluster of seizures: in 8 patients after a cluster of generalized tonic-clonic seizures, in 2 after complex partial seizures, and in 1 patient after a cluster of atypical absence seizures. This series suggests that vulnerability to develop PPIE exists in patients with diffuse structural abnormalities, mild to borderline mental retardation, a history of status epilepticus, and a tendency of seizures to cluster.

p53-independent dephosphorylation and cleavage of retinoblastoma protein during tamoxifen-induced apoptosis in human breast carcinoma cells.

We have investigated several molecular events that occur during the process of tamoxifen-induced apoptosis in human breast carcinoma cells. We show that the treatment of either MCF-7 (containing wild-type p53) or MDA-MB-231 cells (containing mutant p53) with tamoxifen resulted in apoptotic nuclear changes and an increase in the pre-G1 apoptotic population. This was accompanied by activation of the caspase enzymes, as evidenced by specific cleavage of poly(ADP-ribose) polymerase and retinoblastoma (RB) protein. The RB protein was cleaved at both an interior and carboxyl terminus cleavage site. In addition, dephosphorylation of RB was found at an early stage of tamoxifen-induced apoptosis in both cell lines. However, neither induction of p53 in MCF-7 cells nor induction of p21 in either cell line was detected, suggesting that tamoxifen-induced RB dephosphorylation and apoptosis are independent of the p53/p21 pathway. We also observed an increase in levels of the pro-apoptotic Bax protein, the inhibitory cytokine TGF-beta1 and the transcription factor c-Myc in tamoxifen-treated MDA-MB-231 cells, suggesting the possible involvement of these proteins during apoptosis in this system.

Nicotine patch and paroxetine for smoking cessation.

Smokers (N = 224) were randomized to 1 of 3 groups: (a) transdermal system (TNS) + placebo; (b) TNS + paroxetine (20 mg); (c) TNS + paroxetine (40 mg). Assignment to treatment was double-blind. Nicotine patch (TNS) treatment was provided for 8 weeks; paroxetine or placebo was provided for 9 weeks. Abstinence rates at Weeks 4, 10, and 26 were as follows: (a) TNS + placebo: 45%, 36%, and 25%; (b) TNS + paroxetine (20 mg): 48%, 33%, and 21%; (c) TNS + paroxetine (40 mg): 57%, 39%, and 27%. The differences were not statistically significant. The combined treatment was more effective in reducing both craving and depression symptoms associated with smoking cessation. A subgroup analysis comparing compliant participants was also conducted. Abstinence rates at Weeks 4, 10, and 26 were as follows: (a) TNS + placebo: 46%, 35%, and 24%; (b) TNS + paroxetine (20 mg): 64%, 43%, and 33%; (c) TNS + paroxetine (40 mg): 74%, 51%, and 38%. The differences between paroxetine groups and placebo at Week 4 were statistically significant. Although paroxetine may add value to the current standard of care in excess of potential risk, more conclusive evidence is needed.

Treatment-seeking for depression by black and white Americans.

This paper examines data from a psychiatric epidemiologic survey of 3004 households in St Louis to determine whether there are distinctions between black and white Americans in their propensities to seek treatment for episodes of depression and to discover those groups least likely to seek care. The process initiated by the experiencing of unusual or distressing signs or symptoms and completed by seeking treatment for those complaints is a complex one, involving several steps. Numerous factors may affect decisions regarding treatment-seeking including characteristics of the individuals themselves, characteristics of the symptoms, and attitudes and beliefs about the causes and proper treatment of psychiatric problems or mood. We, therefore, also examine the available epidemiologic data for some clues concerning those factors which may have contributed to the observed patterns of treatment-seeking. Significantly fewer blacks meeting psychiatric criteria for a diagnosis of depression had sought professional care. Moreover, severity of the problem was significantly related to treatment-seeking among blacks and it was among those with the least severe problems that the greatest differences were found. Whites did not significantly exceed blacks in seeking care when depressive episodes were long lasting, severe or frequent. Although there was some indication that blacks may be more tolerant of depressive symptoms, a considerable proportion of blacks who felt they had a troublesome problem had never sought professional care. There was little evidence to suggest that a fear of being stigmatized prevented blacks from seeking care. However, blacks were more likely to report that fear of treatment and of being hospitalized had prevented them from seeking care. A number of hypotheses generated by the epidemiologic data are presented. Once large-scale surveys such as this have delineated the patterns of health care utilization and identified those groups at high risk of not receiving care, anthropological concepts and problem-oriented field research may be extremely useful in testing hypotheses concerning those factors underlying the observed behavioral patterns.

Platelet and granulocyte pheresis.

The need for sophisticated component therapy has resulted in improved techniques for obtaining concentrates of platelets and granulocytes. The use of single donors as a source for these products is advisable to avoid multiple sensitizations. A method for obtaining large quantities of platelets has been established rather easily. Obtaining concentrated granulocytes represents a greater problem owing to the difficulty in separating granulocytes from red cells by differential centrifugation or sedimentation since the specific gravities are similar. Separation is easier by the use of hydroxyethyl starch. A modified solution of hydroxyethyl starch and sodium citrate was used with good results.

Restricting symptoms in the last year of life: a prospective cohort study.

IMPORTANCE: Freedom from symptoms is an important determinant of a good death, but little is known about symptom occurrence during the last year of life. OBJECTIVE: To evaluate the monthly occurrence of physical and psychological symptoms leading to restrictions in daily activities (ie, restricting symptoms) among older persons during the last year of life and to determine the associations of demographic and clinical factors with symptom occurrence. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study. Comprehensive assessments were completed every 18 months, and monthly interviews were conducted to assess the presence of restricting symptoms. Of 1002 nondisabled community-dwelling individuals 70 years or older in greater New Haven, Connecticut, eligible to participate, 754 agreed and were enrolled between 1998 and 1999. MAIN OUTCOMES AND MEASURES: The primary outcome was the monthly occurrence of restricting symptoms as a dichotomous outcome. The monthly mean count of restricting symptoms was a secondary outcome. RESULTS: Among the 491 participants who died after their first interview and before June 30, 2011, mean age at death was 85.8 years, 61.9% were women, and 9.0% were nonwhite. The mean number of comorbid conditions was 2.4, and 73.1% had multimorbidity. The monthly occurrence of restricting symptoms was fairly constant from 12 months before death (20.4%) until 5 months before death (27.4%), when it began to increase rapidly, reaching 57.2% in the month before death. In multivariable analysis, age younger than 85 years (odds ratio [OR], 1.30 [95% CI, 1.07-1.57]), multimorbidity (OR, 1.38 [95% CI, 1.09-1.75]), and proximity to time of death (OR, 1.14 per month [95% CI, 1.11-1.16]) were significantly associated with the monthly occurrence of restricting symptoms. Participants who died of cancer had higher monthly symptom occurrence (OR, 1.80 [95% CI, 1.03-3.14]) than participants who died of sudden death, although this difference was only marginally significant (P = .04). Symptom burden did not otherwise differ substantially according to condition leading to death. CONCLUSIONS AND RELEVANCE: Restricting symptoms are common during the last year of life, increasing substantially approximately 5 months before death. Our results highlight the importance of assessing and managing symptoms in older patients, particularly those with multimorbidity.