Adaptation of the Acute Organ Failure Score for Use in a Medicare Population.

OBJECTIVES: Without widely available physiologic data, a need exists for ICU risk adjustment methods that can be applied to administrative data. We sought to expand the generalizability of the Acute Organ Failure Score by adapting it to a commonly used administrative database. DESIGN: Retrospective cohort study. SETTING: One hundred fifty-one hospitals in Pennsylvania. PATIENTS: A total of 90,733 ICU admissions among 77,040 unique patients between January 1, 2009, and December 1, 2009, in the Medicare Provider Analysis and Review database. MEASUREMENTS AND MAIN RESULTS: We used multivariable logistic regression on a random split cohort to predict 30-day mortality, and to examine the impact of using different comorbidity measures in the model and adding historical claims data. Overall 30-day mortality was 17.6%. In the validation cohort, using the original Acute Organ Failure Score model's ß coefficients resulted in poor discrimination (C-statistic, 0.644; 95% CI, 0.639-0.649). The model's C-statistic improved to 0.721 (95% CI, 0.711-0.730) when the Medicare cohort was used to recalibrate the ß coefficients. Model discrimination improved further when comorbidity was expressed as the COmorbidity Point Score 2 (C-statistic, 0.737; 95% CI, 0.728-0.747; p < 0.001) or the Elixhauser index (C-statistic, 0.748; 95% CI, 0.739-0.757) instead of the Charlson index. Adding historical claims data increased the number of comorbidities identified, but did not enhance model performance. CONCLUSIONS: Modification of the Acute Organ Failure Score resulted in good model discrimination among a diverse population regardless of comorbidity measure used. This study expands the use of the Acute Organ Failure Score for risk adjustment in ICU research and outcomes reporting using standard administrative data.

Fatal and nonfatal drowning outcomes related to dangerous underwater breath-holding behaviors - New York State, 1988-2011.

Drowning is an important cause of preventable injury and mortality, ranking fifth among leading causes of unintentional injury death in the United States. In 2011, two healthy young men died in a drowning incident at a New York City (NYC)-regulated swimming facility. The men became unconscious underwater after performing intentional hyperventilation before submersion. The phenomenon of healthy swimmers becoming unconscious underwater has been described elsewhere as hypoxic blackout. Prompted by this incident, the NYC Department of Health and Mental Hygiene (DOHMH) in collaboration with the New York State Department of Health (SDOH) conducted a case review of New York state fatal and nonfatal drownings reported during 1988-2011 to investigate similar behaviors in other incidents. DOHMH identified 16 cases, three in NYC, with a consistent set of voluntary behaviors associated with unintentional drowning and designated this class of behaviors as "dangerous underwater breath-holding behaviors" (DUBBs). For this small sample, the frequency of different DUBBs varied by age and swimming level, and practicing more than one DUBB increased the risk for fatality. This research contributes to the literature on drowning by focusing on contributing behaviors rather than drowning outcomes. NYC recently enacted public health education and regulations that discourage DUBBs; these interventions have the potential to effectively reduce unintentional drowning related to these behaviors and could be considered by other municipalities and jurisdictions.

Rhabdomyolysis Caused by Isotretinoin and Exercise in an Otherwise Healthy Female Patient.

Acne vulgaris is one of the most common skin conditions treated by healthcare providers. Isotretinoin is a well-known and effective treatment for nodulocystic and scarring acne. Rarely, and usually in combination with exercise, patients treated with isotretinoin can develop rhabdomyolysis, a potentially life-threatening breakdown of muscle associated with elevated creatine kinase (CK). Here, we report a rare case of a female patient developing rhabdomyolysis three months after starting exercise and isotretinoin. She was treated with supportive care and medication was discontinued, resulting in a full recovery. Careful inquiry into the patient's exercise habits, along with a thorough review of systems at each visit can help identify high-risk patients. Routine monitoring of liver enzymes, specifically aspartate aminotransferase elevations, may provide a prompt to check a patient's CK. Though regular monitoring of CK is not currently recommended, given the prevalence of regular exercise in certain patient populations, this case reinforces the importance of counseling patients on this potential side effect.

Opioid Prescribing Practices of Orthopaedic Surgeons: Results of a National Survey.

INTRODUCTION: Opioids are widely used after orthopaedic procedures. Nonmedical opioid use is a growing public health issue. METHODS: An anonymous online survey was distributed by e-mail to the orthopaedic societies of all 50 states and several large private practices to assess practicing orthopaedic surgeons' opioid prescribing practices. RESULTS: A total of 555 orthopaedic surgeons practicing in 37 states responded. The most commonly prescribed opioid for both teenagers and adults was hydrocodone/acetaminophen. Of note, 42.3% reported that a patient they have prescribed opioids for developed an opioid dependency, whereas 35.3% do not believe that opioid use is a problem in their practice. Of note, 30.3% reported prescribing refills, and factors significantly associated with increased prescribing of refills included a greater number of years in practice (P < 0.001) and practicing in a suburban rather than an urban or rural environment (P = 0.03). CONCLUSION: Orthopaedic surgeons rarely prescribe any refills, tend to prescribe less opioids to teenagers than adults, and prescribe fairly uniformly for patients who are treated nonsurgically or undergo minor or arthroscopic surgery. They exhibit considerable variation in prescribing for fractures and major procedures.

Return to play after treatment of shoulder labral tears in professional hockey players.

OBJECTIVES: Shoulder labral injuries in professional hockey players are often treated surgically to minimize missed ice time. Previous studies have shown that post-operative outcomes in these players are favorable, although they have not specifically focused on athletic performance and time to return to sport. Our objective was to report time to return to play and post-operative on-ice performance metrics after shoulder labral repair in professional ice hockey players. METHODS: We performed a retrospective review of the clinical records of all professional hockey players (NHL) who underwent arthroscopic shoulder labral repair by one surgeon between January 2004 and December 2008. Operative data included labral injury type, number of anchors used, concomitant pathology, and complications. Player information included position, shooting hand, games played before and after surgery, date of return to play (RTP), time on ice (TOI) and shots on goal before and after surgery. Paired sample t-test and independent sample t-tests or their non-parametric equivalents were used to compare pre-and post-operative player performance variables using the SPSS statistical package. RESULTS: Eleven NHL Players (13 shoulders) were included in the study. The average follow-up was 19.4 months (12.7-37 months, SD 7.4) and average age was 29 years (20-36, SD 5.1). Of the 13 shoulders, there were various types of labral tears including three Bankart tears, three superior (SLAP) tears, two posterior tears, three combined anterior/posterior tears, and two panlabral tears. All 11 players returned to play (RTP) after surgery at an average time of 4.3 months. There were no significant differences between time to RTP for players with dominant-sided injuries (4.2 months) and non-dominant injuries (4.6 months), p = 0.632. Five players had increased time-on-ice (TOI) and five players had decreased TOI after surgery, though this difference was not significant (p = 0.3804). On average, the shots on goal per game played (SOG/GP) decreased by 0.13 after surgery which was not significantly different (p = 0.149). There were no post-operative complications observed. CONCLUSION: Professional ice hockey players can safely return to full competition at an average of 4.3 months after arthroscopic shoulder labral repair without significant decline in player performance.

No improvement in the reporting of clinical trial subgroup effects in high-impact general medical journals.

BACKGROUND: When subgroup analyses are not correctly analyzed and reported, incorrect conclusions may be drawn, and inappropriate treatments provided. Despite the increased recognition of the importance of subgroup analysis, little information exists regarding the prevalence, appropriateness, and study characteristics that influence subgroup analysis. The objective of this study is to determine (1) if the use of subgroup analyses and multivariable risk indices has increased, (2) whether statistical methodology has improved over time, and (3) which study characteristics predict subgroup analysis. METHODS: We randomly selected randomized controlled trials (RCTs) from five high-impact general medical journals during three time periods. Data from these articles were abstracted in duplicate using standard forms and a standard protocol. Subgroup analysis was defined as reporting any subgroup effect. Appropriate methods for subgroup analysis included a formal test for heterogeneity or interaction across treatment-by-covariate groups. We used logistic regression to determine the variables significantly associated with any subgroup analysis or, among RCTs reporting subgroup analyses, using appropriate methodology. RESULTS: The final sample of 416 articles reported 437 RCTs, of which 270 (62 %) reported subgroup analysis. Among these, 185 (69 %) used appropriate methods to conduct such analyses. Subgroup analysis was reported in 62, 55, and 67 % of the articles from 2007, 2010, and 2013, respectively. The percentage using appropriate methods decreased over the three time points from 77 % in 2007 to 63 % in 2013 (p < 0.05). Significant predictors of reporting subgroup analysis included industry funding (OR 1.94 (95 % CI 1.17, 3.21)), sample size (OR 1.98 per quintile (1.64, 2.40), and a significant primary outcome (OR 0.55 (0.33, 0.92)). The use of appropriate methods to conduct subgroup analysis decreased by year (OR 0.88 (0.76, 1.00)) and was less common with industry funding (OR 0.35 (0.18, 0.70)). Only 33 (18 %) of the RCTs examined subgroup effects using a multivariable risk index. CONCLUSIONS: While we found no significant increase in the reporting of subgroup analysis over time, our results show a significant decrease in the reporting of subgroup analyses using appropriate methods during recent years. Industry-sponsored trials may more commonly report subgroup analyses, but without utilizing appropriate methods. Suboptimal reporting of subgroup effects may impact optimal physician-patient decision-making.

Factors associated with mortality in rear-seated adult passengers involved in fatal motor vehicle crashes on US roadways.

BACKGROUND: Recent efforts to pass rear seat belt laws for adults have been hampered by large gaps in the scientific literature. This study examines driver, vehicle, crash, and passenger characteristics associated with mortality in rear-seated adult passengers. METHODS: The Fatality Analysis Reporting System (FARS) 2010 to 2011 was used to examine motor vehicle occupant mortality in rear-seated adult passengers 18 years and older. Side crash vehicle safety ratings were assessed in a subset analysis of vehicles struck on the same side as the rear-seated passenger. Multilevel logistic regression models used SAS GLIMMIX. RESULTS: Of the 7,229 rear-seated adult passengers, 2,091 (28.9%) died. Multivariable predictors of increased mortality were advancing passenger age, younger driver age, excessive speed, ejection, being unbelted, rear impact, and same-side crash. Belt use was associated with a 67.0% reduction in total mortality. Despite this, belt wearing was low (48.1%) and differed by seating position, with less than one third of middle-seated passengers belted. Multivariable analysis showed mortality to be nearly three times higher in same-side crashes than other impact locations (odds ratio (OR) = 2.76, 2.22, 3.44). In a multivariable subpopulation analysis of same-side crashes, right-seated passengers had an increased mortality (52.7% vs. 43.2%, p < 0.01) compared to left-seated passengers (OR = 1.55, 1.02, 2.36). Vehicle side crash safety ratings, available for 27.7% (n = 172) of same-side crashes, were not predictive of mortality. CONCLUSIONS: Except for same-side crashes, seat belts were associated with significantly lowered mortality. Despite this, seat belt wearing was low and represents one of several areas where further improvements in mortality might be realized.