NSQIP Based Predictors of False Negative and Indeterminate Ultrasounds in Adults With Appendicitis.

BACKGROUND: It has been well established that ultrasound (US) is the initial screening tool for children with suspected acute appendicitis. However, computed tomography (CT) has become the standard screening modality for adults presenting with abdominal pain. A recent review of National Surgical Quality Improvement Program (NSQIP) data revealed US is being utilized as a screening modality in adults. We aimed to assess the diagnostic performance of US in evaluating adults with acute appendicitis. STUDY DESIGN: The American College of Surgeons NSQIP and NSQIP Procedure Targeted Data Files were accessed and examined for all patients in 2016 and 2017 who received an US and underwent an appendectomy. The US results were then correlated to the pathology in order to determine the diagnostic performance. Additionally, we identified predictors for indeterminate and false negative US results. RESULTS: Our study included 3607 appendectomy patients of which 1135 (30%) had an indeterminate US, 683 (18%) had an US not consistent with appendicitis, and 1789 (49%) had an US consistent with appendicitis. Sensitivity and Specificity were 74.3% and 53.0%, respectively. Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were 95.9% and 12.2%, respectively. On regression analysis, clinically relevant predictors for false negative and indeterminate studies included age, sex, and BMI. CONCLUSIONS: Ultrasound is an effective initial imaging modality for acute appendicitis in the adult population. Females, age >30 y, and elevated BMI were more likely to have indeterminate or false negative results. These patients may benefit from CT as their initial screening test.

Association between depression and hypertension using classic and revised blood pressure thresholds.

BACKGROUND: In a primary care population, the relationship between treatment of depression and hypertension (HTN) under the recently revised American College of Cardiology and American Heart Association HTN thresholds for diagnosing HTN is unknown. OBJECTIVE: To compare the association between changes in severity of co-occurring depression and HTN over time using the newly revised versus previous HTN guidelines. METHODS: In this retrospective cohort study, outpatients ≥18 years (n = 3018) with clinically significant depressive symptoms and elevated blood pressure at baseline were divided into a 'revised' guideline group (baseline blood pressure ≥130/80 mmHg), a 'classic' guideline group (≥140/90 mmHg) and a 'revised-minus-classic' group (≥130/80 and <140/90 mmHg). Depressive symptom change was assessed using the Patient Health Questionnaire-9 (PHQ-9). Correlations between changes in PHQ-9 scores and HTN levels by group over a 6- to 18-month observation period were assessed using robust regression analysis. RESULTS: There were demographic and clinical differences between groups. A total of 41% of study subjects (1252/3018) had a visit during the follow-up period where additional PHQ-9 and HTN results were available. Depressive symptom change was unrelated to change in blood pressure in the revised and revised-minus-classic groups. The classic HTN group demonstrated a clinically insignificant change in systolic blood pressure for each unit change in PHQ-9 score (ß = 0.23, P-value =0.02). CONCLUSIONS: Although a statistically significant association between reduced HTN levels and improvement in depressive symptoms was demonstrated under classic HTN guidelines, there was no clinically meaningful association between treatment of depression and improved HTN levels under either guideline.

Readmission Outcomes of Sliding Scale Insulin Compared to Basal-Bolus Insulin Prescribed at Discharge in an Insulin-Naive Patient Population.

BACKGROUND: Limited data are available that examine hospital readmission outcomes of sliding scale compared to basal-bolus insulin in indigent and insulin-naive patients. OBJECTIVE: To evaluate hospital readmission outcomes in patients who are insulin naive with type 2 diabetes mellitus who are initiated on either sliding scale or basal-bolus insulin upon hospital discharge. METHODS: A retrospective chart review was conducted of adult patients with a history of type 2 diabetes mellitus, who were insulin naive, had a hemoglobin A1c (HbA1c) 10% or greater, and were discharged with a prescription for sliding scale or basal-bolus insulin from January 2015 to July 2018. The primary objective measured all-cause 30-day hospital readmissions. The secondary objectives measured diabetes-related 30-day hospital readmissions and HbA1c change after 3 months of initial hospital admission. Data were analyzed using descriptive statistics, χ2 test, paired sample t test, and logistic regression. RESULTS: Forty-one patients were prescribed sliding scale insulin and 105 patients were prescribed basal-bolus insulin. The majority were male (60%), spoke English (84%), were self-pay (39%), and had a mean age of 51 ± 10.2 years, initial HbA1c of 13% ± 1.9%, and LACE+ score of 51 ± 15.6 upon discharge. All-cause 30-day hospital readmissions occurred in 14.6% of sliding scale and 6.7% of basal-bolus insulin groups (odds ratio [OR]: 2.40, 95% confidence interval [CI]: 0.75-7.63). Hyperglycemia occurred in 7.3% of sliding scale and 0.9% of basal-bolus insulin groups. Mean HbA1c difference for basal-bolus and sliding scale insulin was 3.3 ± 3.1 and 2.9 ± 2.7, respectively (P = 0.459). CONCLUSION: There was no significant difference in all-cause 30-day hospital readmissions comparing sliding scale to basal-bolus insulin.