THE TRENDS AND INCIDENCE OF ALCOHOL-ASSOCIATED HEPATITIS HOSPITALIZATIONS FROM 2016-2020 AND THE IMPACT OF THE COVID-19 PANDEMIC.

INTRODUCTION: The impact of the COVID-19 pandemic on hospitalizations for alcohol-associated hepatitis (AH) is poorly understood. Here we explore AH trends from 2016-2020 and evaluate demographic disparities including sex and race. METHODS: A retrospective analysis of the 2016-2020 Healthcare Cost and Utilization Project National Inpatient Sample was performed to assess temporal trends in hospitalizations for AH. The 2020 dataset was evaluated to compare AH hospitalizations between those with and without an additional diagnosis of COVID-19. RESULTS: Included were 607,140 weighted inpatient AH discharges per 145,055,152 all-cause discharges from 2016-2020. AH hospitalizations increased at a rate of 23.4 hospitalizations per 100,000 all-cause discharges per year between 2016-2019 and increased to 113 hospitalizations per 100,000 all-cause discharges in 2020. Mortality was higher in females despite lower rates of hospitalization than males. The adjusted odds of hospitalization for AH in 2020 were higher than in 2016-2019 (aOR= 1.28, p < 0.001). The Hispanic population had greater odds of hospitalization with AH and COVID-19 compared to other races (aOR= 2.71, p <0.001). DISCUSSION: Increased efforts toward primary prevention of excessive alcohol use and greater social support for those with alcohol used disorder are needed. More research is required to elucidate the racial disparities among the Hispanic population with AH and COVID-19.

Disparities among ethnic groups in mortality and outcomes among adults with MASLD: A multicenter study.

BACKGROUND: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of chronic liver disease and 10%-20% occurs in lean individuals. There is little data in the literature regarding outcomes in an ethnically-diverse patient populations with MASLD. Thus, we aim to investigate the natural history and ethnic disparities of MASLD patients in a diverse population, and stratified by body mass index categories. METHODS: We conducted a retrospective multicenter study on patients with MASLD at the Banner Health System from 2012 to 2022. Main outcomes included mortality and incidence of cirrhosis, cardiovascular disease, diabetes mellitus (DM), liver-related events (LREs), and cancer. We used competing risk and Cox proportional hazard regression analysis for outcome modelling. RESULTS: A total of 51 452 (cross-sectional cohort) and 37 027 (longitudinal cohort) patients were identified with 9.6% lean. The cohort was 63.33% European ancestry, 27.96% Hispanic ancestry, 3.45% African ancestry, and 2.31% Native American/Alaskan ancestry. Median follow-up was 45.8 months. After adjusting for confounders, compared to European individuals, Hispanic and Native American/Alaskan patients had higher prevalence of cirrhosis and DM, and individuals of Hispanic, African, and Native American/Alaskan ancestry had higher mortality and incidence of LREs and DM. Lean patients had higher mortality and incidence of LREs compared with non-lean patients. CONCLUSION: Native American/Alaskan, Hispanic, and African patients had higher mortality and incidence of LREs and DM compared with European patients. Further studies to explore the underlying disparities and intervention to prevent LREs in lean patients, particularly several ethnic groups, may improve clinical outcomes.

Validation of the RBD Symptom Severity Scale in the North American Prodromal Synucleinopathy Consortium.

BACKGROUND AND OBJECTIVES: REM sleep behavior disorder (RBD) is a parasomnia characterized by dream enactment. The International RBD Study Group developed the RBD Symptom Severity Scale (RBDSSS) to assess symptom severity for clinical or research use. We assessed the psychometric and clinimetric properties of the RBDSSS in participants enrolled in the North American Prodromal Synucleinopathy (NAPS) Consortium for RBD. METHODS: NAPS participants, who have polysomnogram-confirmed RBD, and their bedpartners completed the RBDSSS (participant and bedpartner versions). The RBDSSS contains 8 questions to assess the frequency and severity/impact of (1) dream content, (2) vocalizations, (3) movements, and (4) injuries associated with RBD. Total scores for participant (maximum score = 54) and bedpartner (maximum score = 38) questionnaires were derived by multiplying frequency and severity scores for each question. The Clinical Global Impression Scale of Severity (CGI-S) and RBD symptom frequency were assessed by a physician during a semistructured clinical interview with participants and, if available, bedpartners. Descriptive analyses, correlations between overall scores, and subitems were assessed, and item response analysis was performed to determine the scale's validity. RESULTS: Among 261 study participants, the median (interquartile range) score for the RBDSSS-PT (participant) was 10 (4-18) and that for the RBDSSS-BP (bedpartner) was 8 (4-15). The median CGI-S was 3 (3-4), indicating moderate severity. RBDSSS-BP scores were significantly lower in women with RBD (6 vs 9, p = 0.02), while there were no sex differences in RBDSSS-PT scores (8 vs 10.5, p = 0.615). Positive correlations were found between RBDSSS-PT vs RBDSSS-BP (Spearman rs = 0.561), RBDSSS-PT vs CGI-S (rs = 0.556), and RBDSSS-BP vs CGI-S (rs = 0.491, all p < 0.0001). Item response analysis showed a high discriminatory value (range 1.40-2.12) for the RBDSSS-PT and RBDSSS-BP (1.29-3.47). DISCUSSION: We describe the RBDSSS with adequate psychometric and clinimetric properties to quantify RBD symptom severity and good concordance between participant and bedpartner questionnaires and between RBDSSS scores and clinician-assessed global severity.

Correlation of Joint Space Widening on Valgus Stress Magnetic Resonance Imaging With Level of Play and Innings Pitched in Professional Pitchers.

Background: Previous studies have described various techniques and confirmed the clinical utility of valgus stress radiography and stress ultrasound in overhead athletes. The addition of valgus stress and a high-resolution anatomic assessment of the elbow with magnetic resonance imaging (MRI) in the active throwing position (flexed elbow valgus external rotation [FEVER] view) can add valuable diagnostic or prognostic information in throwing athletes. Purpose/Hypothesis: The purpose of this study was to evaluate findings on MRI and subsequent performance in professional throwing athletes. It was hypothesized that joint space widening in the FEVER view would be predictive of performance and the risk of subsequent injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All pitchers on 2 Major League Baseball teams who consented to participate during their preseason screening in 2019 and 2020 underwent standard and FEVER MRI, and performance data from the following season were recorded, including injuries, mean throwing velocity, number of innings pitched, strikeout percentage, walk percentage, weighted on-base average, and level of play reached (not signed, minor league, or major league). Categorical variables were compared using the Fisher exact test or chi-square test, and continuous variables were compared using the Kruskal-Wallis test, as appropriate. Ordered logistic regression was used to determine the independent factors predicting performance. Results: A total of 91 players underwent preseason imaging, and all players had subsequent performance data available. Multivariate analysis revealed that when controlling for age, mean velocity, history of injuries, presence of symptoms, and history of ulnar collateral ligament reconstruction, increased absolute joint space widening was predictive of a lower level of play (ß = -0.63; P = .042). Univariate analysis demonstrated a significant correlation between relative joint space widening and level of play reached (ß = -0.54; P = .034). Relative joint space widening remained a significant predictor of level of play (ß = -0.87; P = .012) on multivariate analysis. Multivariate analysis also showed that both absolute joint space widening (ß = -13.50; P = .012) and relative joint space widening (ß = -13.60; P = .026) were predictive of the number of innings pitched in the subsequent season. Conclusion: The present study demonstrates that findings on MRI with valgus stress correlated with the level of play reached and number of innings pitched in professional throwing athletes.

Vasovagal Responses to Human Monomorphic Ventricular Tachycardia: Hemodynamic Implications From Sinus Rate Analysis.

BACKGROUND: Factors determining hemodynamic stability during human ventricular tachycardia (VT) are incompletely understood. OBJECTIVES: The purposes of this study were to characterize sinus rate (SR) responses during monomorphic VT in association with hemodynamic stability and to prospectively assess the effects of vagolytic therapy on VT tolerance. METHODS: This is a retrospective analysis of patients undergoing scar-related VT ablation. Vasovagal responses were evaluated by analyzing sinus cycle length before VT induction and during VT. SR responses were classified into 3 groups: increasing (≥5 beats/min, sympathetic), decreasing (≥5 beats/min, vagal), and unchanged, with the latter 2 categorized as inappropriate SR. In a prospective cohort (n = 30) that exhibited a failure to increase SR, atropine was administered to improve hemodynamic tolerance to VT. RESULTS: In 150 patients, 261 VT episodes were analyzed (29% untolerated, 71% tolerated) with median VT duration 1.6 minutes. A total of 52% of VT episodes were associated with a sympathetic response, 31% had unchanged SR, and 17% of VTs exhibited a vagal response. A significantly higher prevalence of inappropriate SR responses was observed during untolerated VT (sustained VT requiring cardioversion within 150 seconds) compared with tolerated VT (84% vs 34%; P < 0.001). Untolerated VT was significantly different between groups: 9% (sympathetic), 82% (vagal), and 32% (unchanged) (P < 0.001). Atropine administration improved hemodynamic tolerance to VT in 70%. CONCLUSIONS: Nearly one-half of VT episodes are associated with failure to augment SR, indicative of an under-recognized pathophysiological vasovagal response to VT. Inappropriate SR responses were more predictive of hemodynamic instability than VT rate and ejection fraction. Vagolytic therapy may be a novel method to augment blood pressure during VT.

Fibrosis-4 Index Score Predicts Concomitant Coronary Artery Diseases Across the Spectrum of Fatty Liver Disease.

BACKGROUND: 25% of US adults have nonalcoholic fatty liver disease (NAFLD). The independent association between hepatic fibrosis and cardiovascular disease remains controversial. Metabolic dysfunction-associated fatty liver disease (MAFLD) precisely characterizes hepatic steatosis. AIM: We aimed to determine if degree of hepatic fibrosis, with differing metabolic risk factors, is associated with presence of coronary artery disease (CAD). METHODS: Retrospective review of patients with hepatic steatosis at a single center from January 2016-October 2020 was performed. MAFLD diagnosis was based on presence of fatty liver disease and metabolic factors. Descriptive statistics and stepwise multivariable logistic regression were performed. RESULTS: 5288 patients with hepatic steatosis were included. 2821 patients with steatosis and metabolic risks were classified as NAFLD-MAFLD. 1245 patients with steatosis without metabolic risks were classified as non-MAFLD NAFLD. 812 patients with metabolic risks and other liver disease and were classified as non-NAFLD MAFLD. On Multivariate analysis, Fib-4 ≥ 2.67 was an independent risk factor for CAD in the overall fatty liver disease and NAFLD-MAFLD groups. Fib-4 as a continuous variable showed linear association with CAD risk in the overall fatty liver disease, Non-MAFLD NAFLD and NAFLD-MAFLD groups, at Fib-4 values below 2.67. CONCLUSION: Fib-4 ≥ 2.67 is independently predicts concomitant CAD in patients with hepatic steatosis. Fib-4, at levels below 2.67, is significantly associated with concomitant CAD in the all fatty liver disease, Non-MAFLD NAFLD, and NAFLD-MAFLD groups. Emphasizing clinical phenotypes and Fib-4 levels may help target those with an increased risk for CAD.

Biomarkers of gut barrier dysfunction in obstructive sleep apnea: A systematic review and meta-analysis.

We conducted this systematic review and meta-analysis to evaluate the impact of obstructive sleep apnea (OSA) on gut barrier dysfunction as represented by the following biomarkers: zonulin, lipopolysaccharide, lipopolysaccharide binding protein, intestinal fatty acid binding protein, and lactic acid. A comprehensive search of the literature was conducted in Ovid MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov without language restrictions from inception to October 2022. The analysis of all outcomes was performed using a random-effects model. We included eight studies (seven cross sectional and one case control) in the final quantitative synthesis with a total of 897 patients. We concluded that OSA was associated with higher levels of gut barrier dysfunction biomarkers [Hedges' g = 0.73 (95%CI 0.37-1.09, p < 0.01). Biomarker levels were positively correlated with the apnea-hypopnea index [r = 0.48 (95%CI 0.35-0.6, p < 0.01)] and oxygen desaturation index [r = 0.30 (95%CI 0.17-0.42, p < 0.01)], and negatively correlated with the nadir oxygen desaturation values [r = -0.45 (95%CI - 0.55 - - 0.32, p < 0.01). Our systematic review and meta-analysis suggests that OSA is associated with gut barrier dysfunction. Furthermore, OSA severity appears to be correlated with higher biomarkers of gut barrier dysfunction. PROSPERO REGISTRATION NUMBER: CRD42022333078.

Antithrombotic Therapy and Hematoma Risk during Image-guided Core-Needle Breast Biopsy.

Background For image-guided core-needle breast biopsy (CNBB), it remains unclear whether antithrombotic medication should be withheld because of hematoma risk. Purpose To determine hematoma risk after CNBB in patients receiving antithrombotic medication and to stratify risk by antithrombotic type. Materials and Methods This HIPAA-compliant retrospective study included US-, stereotactic-, or MRI-guided CNBBs performed across six academic and six private practices between April 2019 and April 2021. Patients were instructed to continue antithrombotic medications, forming two groups: antithrombotic and nonantithrombotic. Hematomas were defined as new biopsy-site masses with a diameter of 2 cm or larger on postprocedure mammograms. Hematomas were considered clinically significant if management involved an intervention other than manual compression. Patient age, type of antithrombotic medication, practice type, image guidance modality, needle gauge and type, and outcome of pathologic analysis were recorded. Multivariable logistic regression analysis was used to analyze variables associated with hematomas. Results A total of 3311 biopsies were performed in 2664 patients (median age, 60 years; IQR, 48-70 years; 2658 women). The nonantithrombotic group included 2788 biopsies, and the antithrombotic group included 523 biopsies (328 low-dose aspirin, 73 full-dose antiplatelet drugs, 51 direct oral anticoagulants, 36 warfarin, 32 daily nonsteroidal anti-inflammatory drugs, three heparin or enoxaparin). The antithrombotic group had a higher overall hematoma rate (antithrombotic group: 49 of 523 biopsies [9.4%], nonantithrombotic group: 172 of 2788 biopsies [6.2%]; P = .007), but clinically significant hematoma rates were not different (antithrombotic group: two of 523 biopsies [0.4%], nonantithrombotic group: one of 2788 biopsies [0.04%]; P = .07). At multivariable analysis, age (odds ratio [OR], 1.02; 95% CI: 1.01, 1.03; P < .001), 9-gauge or larger needles (OR, 2.1; 95% CI: 1.28, 3.3; P = .003), and full-dose antiplatelet drugs (OR, 2.5; 95% CI: 1.29, 5.0; P = .007) were associated with higher hematoma rates. US guidance (OR, 0.26; 95% CI: 0.17, 0.40; P < .001) and 10-14-gauge needles (OR, 0.53; 95% CI: 0.36, 0.79; P = .002) were predictive of no hematoma. Conclusion Because clinically significant hematomas were uncommon, withholding antithrombotic medications before core-needle breast biopsy may be unnecessary. Postbiopsy hematomas were associated with full-dose antiplatelet drugs, patient age, and 9-gauge or larger needles. No association was found with other types of antithrombotic medication. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Chang and Yoen in this issue.

Timing and Outcomes of Percutaneous Endoscopic Gastrostomy After Ischemic Stroke.

Background: Guidelines recommend using percutaneous endoscopic gastrostomy (PEG) for dysphagia after 2 weeks of stroke onset. We aimed to study the impact of PEG timing on outcomes in patients with ischemic stroke. Methods: In this retrospective study of patients with ischemic stroke and PEG between 2014 and 2019, early PEG was defined as PEG tube placed within 14 days of stroke and late PEG after 14 days. Outcomes of 30-day mortality, PEG-related complications, and functional swallow recovery were compared between early and late PEG. Logistic regression model assessed factors associated with PEG timing. Results: The median time of PEG tube placement after stroke was 10.9 days. Of the 161 included patients, 60.9% had early PEG, and its associated patient factors were nursing facility discharge (adjusted odds ratio (OR): 3.4, confidence interval (CI): 1.48 - 7.82) and infection (OR: 0.32, CI: 0.139 - 0.178). Late PEG had 3.27 times greater odds of swallowing recovery, but mortality and complications were not significantly different between early and late PEG. Conclusions: Skilled nursing facility disposition and lack of infection were predictors of early PEG, constituting the majority of PEG placed for ischemic stroke-related dysphagia. Although better odds of swallowing recovery were seen with late PEG, likely implicating better patient selection, overall, the timing of PEG tube placement did not impact short-term mortality and complications.

Vancomycin With Concomitant Piperacillin/Tazobactam vs. Cefepime or Meropenem Associated Acute Kidney Injury in General Ward Patients: A Multicenter Propensity Score-Matched Study.

Background: Concurrent administration of vancomycin and piperacillin/tazobactam (VAN+PTZ) may increase the risk of acute kidney injury (AKI) in hospitalized patients. Comprehensive characterization of VAN+PTZ associated AKI and recovery patterns remains lacking in previous reports. Objective: To compare the incidence of AKI associated with VAN+PTZ compared to either cefepime (CEF) or meropenem (MER) with VAN in adult general ward patients. Methods: A multicenter, retrospective, propensity score cohort study was conducted in non-critically ill adult patients. Included patients were concurrently administered VAN+PTZ or VAN+CEF/MER. Patients developing AKI ≤48 hours following combination therapy were excluded. The primary endpoint was to compare the incidence of AKI between study groups. Multivariable Cox regression modeling in predicting AKI was also conducted. Results: A total of 3199 patients met inclusion criteria and were evaluated. The incidence of AKI in VAN+PTZ and VAN+CEF/MER groups were 16.4% and 8.7%, respectively (P < .001). The onset to AKI was 1.8 days earlier with VAN+PTZ compared to VAN+CEF/MER (P < .001). Multivariable prediction model showed concomitant VAN+PTZ was identified as an independent risk factor of developing AKI (HR 2.34, 1.82-3.01, P < .001). The VAN+PTZ group experienced significantly higher rates of severe AKI (stage II or III) compared to the VAN+CEF/MER group (P = .002). No differences in the AKI recovery patterns were found between study groups. Conclusions: Concomitant VAN+PTZ in adult general ward patients was independently associated with an increased risk of AKI overall. More severe AKI was also associated with VAN+PTZ.

Effectiveness of Casirivimab-Imdevimab Monoclonal Antibody Treatment Among High-Risk Patients With Severe Acute Respiratory Syndrome Coronavirus 2 B.1.617.2 (Delta Variant) Infection.

Background: Real-world data on the effectiveness of neutralizing casirivimab-imdevimab monoclonal antibody (Cas-Imd mAb) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among high-risk patients may inform the response to future SARS-CoV-2 variants. Methods: This study covers an observational retrospective data analysis in Banner Health Care System sites, mainly in Arizona. During the study period, the prevalence of SARS-CoV-2 Delta variant was between 95% and 100%. Of 29 635 patients who tested positive for coronavirus disease 2019 (COVID-19) between 1 August 2021 and 30 October 2021, in the Banner Health Care System, the study cohort was split into 4213 adult patients who received Cas-Imd mAb (1200 mg) treatment compared to a PS-matched 4213 untreated patients. The primary outcomes were the incidence of all-cause hospitalization, intensive care unit (ICU) admission, and mortality within 30 days of Cas-Imd mAb administration or Delta variant infection. Results: Compared to the PS-matched untreated cohort, the Cas-Imd mAb cohort had significantly lower all-cause hospitalization (4.2% vs 17.6%; difference in percentages, -13.4 [95% confidence interval {CI}, -14.7 to -12.0]; P < .001), ICU admission (0.3% vs 2.8%; difference, -2.4 [95% CI, -3.0 to -1.9]; P < .001), and mortality (0.2% vs 2.0%; difference, -1.8 [95% CI, -2.3 to -1.3]; P < .001) within 30 days. The Cas-Imd mAb treatment was associated with lower rate of hospitalization (hazard ratio [HR], 0.22 [95% CI, .19-.26]; P < .001) and mortality (HR, 0.11 [95% CI, .06-.21]; P < .001). Conclusions: Cas-Imd mAb treatment was associated with a lower hospitalization rate, ICU admission, and mortality within 30 days among patients infected with the SARS-CoV-2 Delta variant.

COVID-19 Time of Intubation Mortality Evaluation (C-TIME): A system for predicting mortality of patients with COVID-19 pneumonia at the time they require mechanical ventilation.

BACKGROUND: An accurate system to predict mortality in patients requiring intubation for COVID-19 could help to inform consent, frame family expectations and assist end-of-life decisions. RESEARCH OBJECTIVE: To develop and validate a mortality prediction system called C-TIME (COVID-19 Time of Intubation Mortality Evaluation) using variables available before intubation, determine its discriminant accuracy, and compare it to acute physiology and chronic health evaluation (APACHE IVa) and sequential organ failure assessment (SOFA). METHODS: A retrospective cohort was set in 18 medical-surgical ICUs, enrolling consecutive adults, positive by SARS-CoV 2 RNA by reverse transcriptase polymerase chain reaction or positive rapid antigen test, and undergoing endotracheal intubation. All were followed until hospital discharge or death. The combined outcome was hospital mortality or terminal extubation with hospice discharge. Twenty-five clinical and laboratory variables available 48 hours prior to intubation were entered into multiple logistic regression (MLR) and the resulting model was used to predict mortality of validation cohort patients. Area under the receiver operating curve (AUROC) was calculated for C-TIME, APACHE IVa and SOFA. RESULTS: The median age of the 2,440 study patients was 66 years; 61.6 percent were men, and 50.5 percent were Hispanic, Native American or African American. Age, gender, COPD, minimum mean arterial pressure, Glasgow Coma scale score, and PaO2/FiO2 ratio, maximum creatinine and bilirubin, receiving factor Xa inhibitors, days receiving non-invasive respiratory support and days receiving corticosteroids prior to intubation were significantly associated with the outcome variable. The validation cohort comprised 1,179 patients. C-TIME had the highest AUROC of 0.75 (95%CI 0.72-0.79), vs 0.67 (0.64-0.71) and 0.59 (0.55-0.62) for APACHE and SOFA, respectively (Chi2 P<0.0001). CONCLUSIONS: C-TIME is the only mortality prediction score specifically developed and validated for COVID-19 patients who require mechanical ventilation. It has acceptable discriminant accuracy and goodness-of-fit to assist decision-making just prior to intubation. The C-TIME mortality prediction calculator can be freely accessed on-line at https://phoenixmed.arizona.edu/ctime.

Risk factors and management of hepatic artery stenosis post liver transplantation.

BACKGROUND: Hepatic Artery Stenosis (HAS) after liver transplantation (LT), if untreated, can lead to hepatic artery thrombosis (HAT) that carries significant morbidity. AIMS: To identify risk factors associated with HAS and determine if endovascular therapy (EVT) reduces the occurrence of HAT. METHODS: This is a retrospective cohort study of adult LT patients between 2013 and 2018. The primary outcome was development of HAT, and secondary outcomes included graft failure and mortality. Logistic regression was used to ascertain the odds ratio of developing HAS. Outcomes between intervention types were compared with Fisher's-exact test. RESULTS: The odds of HAS doubled in DCD-donor recipients (OR=2.27; P = 0.04) and transplants requiring vascular reconstruction for donor arterial variation (OR=2.19, P = 0.046). Of the 63 identified HAS patients, 44 underwent EVT, 7 with angioplasty alone, 37 combined with stenting. HAT was not significantly different in those who underwent angioplasty with or without stenting than conservative treatment (P = 0.71). However, compared to patients without HAS, patients with HAS had higher odds of biliary stricture and decreased graft and overall patient survival (log-rank P < 0.001 & P = 0.019, respectively). CONCLUSION: HAS is significantly higher in DCD-graft recipients. EVT was not associated with reduction in HAT progression. HAS has poor graft and overall survival.

The Effect of an Automated Order on Postpartum Opioid Use After Uncomplicated Vaginal Deliveries.

Background: To address the opioid epidemic, physicians are encouraged to identify means of reducing patient opioid exposure. Electronic medical records (EMRs) often include default order sets with automated orders for opioid medications, which may influence how much opioids physicians prescribe. We sought to evaluate the impact of de-selecting an automated order for oxycodone-acetaminophen from an EMR order set for postpartum vaginal deliveries on inpatient opioid exposure by comparing the proportion of patients who received an opioid after an uncomplicated vaginal delivery before and after the EMR change. As secondary outcomes, the impact on average total morphine milligram equivalents (MMEs) and discharge opioid prescriptions was investigated. Materials and Methods: A quality improvement study was conducted through retrospective chart review of uncomplicated vaginal deliveries for the four quarters before and after the EMR order set change occurred. The total proportion of patients who received an opioid in the postpartum period was then determined for the preexposure and postexposure groups. The total average MME consumed for patients who received an opioid in each group was determined and the total proportion of patients who received an opioid prescription at discharge was compared. Results: A total of 5826 records of uncomplicated vaginal deliveries met the criteria for analysis. In the preintervention group, 32.9% of patients received an opioid postpartum, compared to 12.5% of patients in the postintervention group, representing a decrease of 62.0% (p < 0.001). Of those who received opioids, the preintervention mean total opioid consumption was 28.4 MME (±27.6) compared to 33.6 MME (±46.4) postintervention, and there was no significant difference in median total opioid consumption: 22.5 MME (interquartile range [IQR]: 7.5-47.5) preintervention compared with 20.8 MME (IQR: 7.5-45.0) postintervention (p = 0.902). No significant difference was found with discharge opioid prescriptions between the two groups. Conclusion: Order sets within EMR systems appear to have a significant influence on physician prescribing behaviors and removing these automated orders for opioids should be considered.

Vancomycin with concomitant piperacillin/tazobactam vs. cefepime or meropenem associated acute kidney injury in the critically ill: A multicenter propensity score-matched study.

PURPOSE: The risk of acute kidney injury (AKI) associated with concomitant vancomycin and piperacillin/tazobactam in the intensive care unit (ICU) remains controversial. The aim of this study was to compare the AKI incidence associated with concomitant vancomycin and piperacillin/tazobactam compared to either cefepime or meropenem with vancomycin in the ICU. MATERIALS AND METHODS: A multicenter, retrospective, propensity score-matched cohort study was conducted in adult ICU patients administered vancomycin in combination with either piperacillin/tazobactam, cefepime, or meropenem were included. Patients developing AKI ≤48 h following combination therapy initiation were excluded. The primary endpoint was to compare the incidence of AKI associated with concomitant antimicrobial therapy. Multivariable Cox regression modeling in predicting AKI was also conducted. RESULTS: A total of 1044 patients were matched. The AKI incidence in vancomycin- piperacillin/tazobactam and vancomycin-cefepime/meropenem groups were 21.9% and 16.8%, respectively (p = 0.068). Multivariable prediction models showed concomitant vancomycin-piperacillin/tazobactam was an independent risk factor of AKI using serum creatinine only (HR 1.52, 1.10-2.10, p = 0.011) and serum creatinine with urine output-based KDIGO criteria (HR 1.77, 1.18-2.67, p = 0.006). No significant differences between groups were observed for AKI recovery patterns or mortality. CONCLUSION: Concomitant vancomycin and piperacillin/tazobactam administration in adult ICU patients was independently associated with an increased risk of AKI.

Obstructive sleep apnea and COVID-19 clinical outcomes during hospitalization: a cohort study.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is an extremely common sleep disorder. A potential association between OSA and coronavirus disease 2019 (COVID-19) severity has been proposed on the basis of similar comorbid medical conditions associated with both OSA and COVID-19. METHODS: We performed a retrospective review of 1,738 patients who were hospitalized with COVID-19 between March and October of 2020. Patients were classified based on the presence or absence of OSA diagnosis based upon the International Classification of Diseases (ICD; codes G47.33 and U07.1 for OSA and COVID-19, respectively). Other data were collected, including demographics, body mass index, and comorbid conditions. COVID-19 severity was compared between groups using the quick COVID-19 severity index. RESULTS: Quick COVID-19 severity index scores were higher in patients with OSA compared with those without OSA. However, the prevalence rates of type 2 diabetes (P < .0001), coronary artery disease (P < .0001), congestive heart failure (P < .0001), and chronic obstructive pulmonary diseases (P < .0001) were also significantly greater in the OSA group. Unadjusted models revealed higher risk of intensive care unit admission in patients with COVID-19 and OSA. However, such an association was attenuated and became nonsignificant after adjusting for age, sex, body mass index, and comorbid disease. CONCLUSIONS: In our study, OSA does not appear to be an independent risk factor for worse COVID-19 outcomes in hospitalized patients. Further studies with larger sample sizes are needed to delineate the potential role of OSA in determining outcomes in hospitalized patients with COVID-19. CITATION: Mashaqi S, Lee-Iannotti J, Rangan P, et al. Obstructive sleep apnea and COVID-19 clinical outcomes during hospitalization: a cohort study. J Clin Sleep Med. 2021;17(11):2197-2204.

A Meta-Analysis of the Association between Helicobacter pylori Infection and Risk of Coronary Heart Disease from Published Prospective Studies.

BACKGROUND: The association between helicobacter pylori (Hp) infection and coronary heart disease (CHD) has long been debated, and the results from previous meta-analysis are varied. AIMS: The aim for this study was to identify the association between Hp and CHD using published perspective cohort studies. MATERIALS AND METHODS: A systematic review and meta-analysis were performed on studies published from January, 1992 to April, 2014. All studies included used data from prospective cohort studies of CHD events or CHD deaths. Random effect models were applied in all estimations. RESULTS: H. pylori infection increased the risk of CHD events by 11% (19 studies, n = 22,207, risk ratio (RR) = 1.11, 95% confidence interval (CI): 1.01-1.22). This effect was greater for studies that had less than 5 years' follow-up time (RR = 1.15, 95% CI: 1.00-1.32). However, this effect was not significant for studies that had follow-up times ≥10 years (n = 5100, RR = 1.04, 95% CI: 0.87-1.24). Neither Cag-A seropositive nor Cag-A seronegative strains of H. pylori were associated with a significantly increased risk of CHD events or deaths based on the current published data. CONCLUSION: In conclusion, H. pylori infection increased the risk of CHD events, especially in a patient's early life, but this association was weaker or might be masked by other CHD risk factors in long-term observations.

Florid plasmacytosis in a case of acute myeloid leukemia: A diagnostic dilemma.

The association of acute myeloid leukemia (AML) with plasmacytosis is a known, although rare event. There are very few case reports documenting an increase in the number of plasma cells at the time of AML diagnosis. Here, we present the case of a 65-year-old male diagnosed as acute myelomonocytic leukemia with exuberant plasmacytosis, which posed a difficulty in diagnosis. Paracrine interleukin-6 production by leukemic blast cells is thought to contribute to this associated reactive plasma cell proliferation.