Assessment of Insulin Infusion Requirements in COVID-19-Infected Patients With Diabetic Ketoacidosis.

BACKGROUND/OBJECTIVE: Coronavirus disease 2019 (COVID-19) is thought to contribute to diabetic ketoacidosis (DKA) and worse outcomes in patients with diabetes. This study compared the cumulative insulin dose required to achieve DKA resolution in the intensive care unit among patients with type 2 diabetes and COVID-19 infection versus without COVID-19 infection. METHODS: This retrospective cohort study evaluated 100 patients-50 patients with COVID-19 in cohort 1 and 50 patients without COVID-19 in cohort 2-treated with insulin infusions for DKA at a tertiary care teaching hospital. The primary outcome was to compare the cumulative insulin dose required to achieve DKA resolution in each cohort. The secondary outcomes included time to DKA resolution, mean insulin infusion rate, and mean weight-based cumulative insulin infusion dose required to achieve DKA resolution. All endpoints were adjusted for confounders. RESULTS: The mean cumulative insulin dose was 190.3 units in cohort 1 versus 116.4 units in cohort 2 (P = .0038). Patients receiving steroids had a mean time to DKA resolution of 35.9 hours in cohort 1 versus 15.6 hours in cohort 2 (P = .0014). In cohort 1 versus cohort 2, the mean insulin infusion rate was 7.1 units/hour versus 5.3 units/hour (P = .0025), whereas the mean weight-based cumulative insulin infusion dose was 2.1 units/kg versus 1.5 units/kg (P = .0437), respectively. CONCLUSION: COVID-19-infected patients required a significantly larger cumulative insulin dose, longer time to DKA resolution, higher insulin infusion rate, and higher weight-based insulin infusion dose to achieve DKA resolution versus non-COVID-19-infected patients with type 2 diabetes.

External validation of the IMPROVE-DD risk assessment model for venous thromboembolism among inpatients with COVID-19.

There is a need to discriminate which COVID-19 inpatients are at higher risk for venous thromboembolism (VTE) to inform prophylaxis strategies. The IMPROVE-DD VTE risk assessment model (RAM) has previously demonstrated good discrimination in non-COVID populations. We aimed to externally validate the IMPROVE-DD VTE RAM in medical patients hospitalized with COVID-19. This retrospective cohort study evaluated the IMPROVE-DD VTE RAM in adult patients with COVID-19 admitted to one of thirteen Northwell Health hospitals in the New York metropolitan area between March 1, 2020 and April 27, 2020. VTE was defined as new-onset symptomatic deep venous thrombosis or pulmonary embolism. To assess the predictive value of the RAM, the receiver operating characteristic (ROC) curve was plotted and the area under the curve (AUC) was calculated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Of 9407 patients who met study criteria, 274 patients developed VTE with a prevalence of 2.91%. The VTE rate was 0.41% for IMPROVE-DD score 0-1 (low risk), 1.21% for score 2-3 (moderate risk), and 5.30% for score ≥ 4 (high risk). Approximately 45.7% of patients were classified as high VTE risk, 33.3% moderate risk, and 21.0% low risk. Discrimination of low versus moderate-high VTE risk demonstrated sensitivity 0.971, specificity 0.215, PPV 0.036, and NPV 0.996. ROC AUC was 0.703. In this external validation study, the IMPROVE-DD VTE RAM demonstrated very good discrimination to identify hospitalized COVID-19 patients at low, moderate, and high VTE risk.

Validation of the IMPROVE-DD risk assessment model for venous thromboembolism among hospitalized patients with COVID-19.

BACKGROUND: Antithrombotic guidance statements for hospitalized patients with coronavirus disease 2019 (COVID-19) suggest a universal thromboprophylactic strategy with potential to escalate doses in high-risk patients. To date, no clear approach exists to discriminate patients at high risk for venous thromboembolism (VTE). OBJECTIVES: The objective of this study is to externally validate the IMPROVE-DD risk assessment model (RAM) for VTE in a large cohort of hospitalized patients with COVID-19 within a multihospital health system. METHODS: This retrospective cohort study evaluated the IMPROVE-DD RAM on adult inpatients with COVID-19 hospitalized between March 1, 2020, and April 27, 2020. Diagnosis of VTE was defined by new acute deep venous thrombosis or pulmonary embolism by Radiology Department imaging or point-of-care ultrasound. The receiver operating characteristic (ROC) curve was plotted and area under the curve (AUC) calculated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using standard methods. RESULTS: A total of 9407 patients were included, with a VTE prevalence of 2.9%. The VTE rate was 0.4% for IMPROVE-DD score 0-1 (low risk), 1.3% for score 2-3 (moderate risk), and 5.3% for score ≥ 4 (high risk). Approximately 45% of the total population scored high VTE risk, while 21% scored low VTE risk. IMPROVE-DD discrimination of low versus medium/high risk showed sensitivity of 0.971, specificity of 0.218, PPV of 0.036, and NPV of 0.996. ROC AUC was 0.702. CONCLUSIONS: The IMPROVE-DD VTE RAM demonstrated very good discrimination to identify hospitalized patients with COVID-19 as low, moderate, and high VTE risk in this large external validation study with potential to individualize thromboprophylactic strategies.

Does Heart Valve Team Risk Assessment Predict Outcomes after Transcatheter Aortic Valve Replacement?

Consideration for transcatheter aortic valve replacement (TAVR) necessitates an integrated risk assessment by members of the Heart Valve Team. The utility of the integrated risk assessment for predicting TAVR outcomes is not established. This article aims to compare the utility of the integrated risk assessment to that of the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score for predicting patient outcomes after TAVR. A total of 274 patients who underwent TAVR from January 2016 to August 2017 were included in this study. Patients were deemed intermediate or high risk by two surgeons on the Heart Valve Team based on an integrated risk assessment that incorporates the STS-PROM score, fragility measures, end-organ dysfunction, and surgeon evaluation. Patients were also deemed low, intermediate, or high risk based solely on their STS-PROM scores of <3%, ≥3% to <8%, and ≥8%, respectively. Differences in postoperative outcomes between intermediate- and high-risk groups as categorized by the integrated risk assessment versus STS-PROM were compared. There were no statistically significant differences in postoperative outcomes between patients who were deemed high and intermediate risk by the Heart Valve Team risk assessment. In contrast, postoperative complication rates were significantly higher in patients deemed high risk as compared with intermediate risk by STS-PROM. Integrated risk assessment by the Heart Valve Team is not superior to STS-PROM in predicting postoperative outcomes in patients undergoing TAVR.

Association of Disposable Perioperative Jackets With Surgical Site Infections in a Large Multicenter Health Care Organization.

Importance: To help prevent surgical site infections (SSIs), recommendations by a national organization led to implementation of a mandatory operating room policy in a large multicenter health care organization of required use of disposable perioperative jackets. Objective: To assess whether the use of perioperative disposable jackets is associated with the incidence of SSIs. Design, Setting, and Participants: Surgical site infection data for patients undergoing clean surgical procedures were retrospectively reviewed from 12 hospitals in a large multicenter health care organization during a 55-month period from January 1, 2014, to July 31, 2018. The incidence of SSI was analyzed for all National Healthcare Safety Network monitored and reported procedures. The patient population was split into 2 groups; the preintervention group consisted of 29 098 patients within the 26 months before the policy starting March 1, 2016, and the postintervention group consisted of 30 911 patients within 26 months after the policy. Main Outcome and Measures: Comparison of the incidence of SSIs before and after intervention periods underwent statistical analysis. The total number of disposable jackets purchased and total expenditures were also calculated. Exposures: Implementation of the mandated perioperative attire policy. Results: A total of 60 009 patients (mean [SD] age, 62.8 [13.9] years; 32 139 [53.6%] male) were included in the study. The overall SSI incidence for clean wounds was 0.87% before policy implementation and 0.83% after policy implementation, which was not found to be significant (odds ratio [OR], 0.96; 95% CI, 0.80-1.14; P = .61). After accounting for possible confounding variables, a multivariable analysis demonstrated no significant reduction in SSIs (OR, 0.85; 95% CI, 0.71-1.01; P = .07). During the postintervention study period (26 months), a total of 2 010 040 jackets were purchased, which amounted to a cost of $1 709 898.46. Conclusions and Relevance: The results of this study suggest that the use of perioperative disposable jackets is not associated with reductions in SSI for clean wounds in a large multicenter health care organization and presents a fiscal burden.

A critical assessment of supported decision-making for persons aging with intellectual disabilities.

Supported decision-making is increasingly being promoted as an alternative to guardianship for persons aging with intellectual disabilities. Proponents argue that supported decision-making, unlike guardianship, empowers persons with disabilities by providing them with help in making their own decisions, rather than simply providing someone else to make decisions for them. To evaluate the empirical support for these claims, we reviewed the evidence base on supported decision-making. Our review found little such empirical research, suggesting that significant further research is warranted to determine whether--and under what conditions--supported decision-making can benefit persons with intellectual disabilities. Indeed, without more empirical evidence as to how supported decision-making functions in practice, it is too early to rule out the possibility it may actually disempower individuals with disabilities by facilitating undue influence by their alleged supporters. We therefore suggest several key areas for future research.

Critical thinking of registered nurses in a fellowship program.

BACKGROUND: Critical thinking is essential to nursing practice. This study examined differences in the critical thinking dispositions of registered nurses (RNs) in a nursing fellowship program. METHODS: Control and experimental groups were used to compare differences in scores on the California Critical Thinking Disposition Inventory (CCTDI) of RNs at three points during a fellowship program: baseline, week 7, and month 5. The control group consisted of RNs who received no education in critical thinking. The experimental group received education in critical thinking using simulated scenarios and reflective journaling. RESULTS: CCTDI scores examined with analysis of variance showed no significant difference within groups over time or between groups. The baseline scores of the experimental group were slightly higher than those of the control group. Chi-square analysis of demographic variables between the two groups showed no significant differences. CONCLUSION: Critical thinking dispositions are a combination of attitudes, values, and beliefs that make up one's personality based on life experience. Lack of statistical significance using a quantitative approach did not capture the development of the critical thinking dispositions of participants. A secondary qualitative analysis of journal entries is being conducted.

Usefulness of the neutrophil-to-lymphocyte ratio in predicting short- and long-term mortality in breast cancer patients.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR) is a strong predictor of mortality in patients with colorectal, gastric, hepatocellular, pancreatic, and lung cancer. To date, the utility of NLR to predict mortality in breast cancer patients has not been studied. Therefore, the aim of our study was to determine whether the NLR is predictive of short- and long-term mortality in breast cancer patients. METHODS: Our observational study used an unselected cohort of breast cancer patients treated at the Staten Island University Hospital between January 2004 and December 2006. A total of 316 patients had a differential leukocyte count recorded prior to chemotherapy. Survival status was retrieved from our cancer registry and Social Security death index. Survival analysis, stratified by NLR quartiles, was used to evaluate the predictive value of NLR. RESULTS: Patients in the highest NLR quartile (NLR > 3.3) had higher 1-year (16% vs 0%) and 5-year (44% vs 13%) mortality rates compared with those in the lowest quartile (NLR < 1.8) (P < .0001). Those in the highest NLR quartile were statistically significantly older and had more advanced stages of cancer. After adjusting for the factors affecting the mortality and/or NLR (using two multivariate models), NLR level > 3.3 remained an independent significant predictor of mortality in both models (hazard ratio 3.13, P = .01) (hazard ratio 4.09, P = .002). CONCLUSION: NLR is an independent predictor of short- and long-term mortality in breast cancer patients with NLR > 3.3. We suggest prospective studies to evaluate the NLR as a simple prognostic test for breast cancer.

Benefits of a comprehensive, publicly funded prenatal care and obstetrics program.

OBJECTIVE: To demonstrate the effectiveness of a comprehensive, multispecialty, interdisciplinary team approach to prenatal and obstetric care for previously medically underserved patients. STUDY DESIGN: A retrospective chart review analysis was performed on a total of 1,800 charts pertaining to 600 patients divided evenly between a publicly funded, comprehensive prenatal care program and that same institution's private faculty practice. For each of the 600 patients data were extracted from prenatal, intrapartum and postpartum records. Data were analyzed using Fisher's exact test, the chi2 test and the Mann-Whitney test. In addition, for certain parameters, the data from the publicly funded program were compared to national data. RESULTS: In the publicly funded group, more patients initiated prenatal care at a later date (p < 0.0001), had a significantly higher rate of illegal substance use (p < 0.0007), utilized home care services more frequently (p < 0.0001) and averaged a somewhat longer hospital stay for mother and neonate (p < 0.0019, p < 0.0001, respectively). However, there was no significant difference between the 2 groups or between the publicly funded group and the national averages for most antepartum, intrapartum and postpartum complications or for maternal or fetal morbidity or mortality. The publicly funded group averaged a higher rate of breast-feeding. CONCLUSION: Despite belonging to a higher risk population, there were no statistically significant differences in maternal or neonatal outcomes between the publicly funded group and the private faculty practice group or between the publicly funded group and national data. This suggests that a comprehensive, multispecialty, interdisciplinary team approach to prenatal and obstetric care is an effective program to provide to patients who have previously been medically underserved.

Tobacco and law enforcement officers.

The literature on the prevalence of health hazards faced by law enforcement officers indicates that they are at high risk for several morbid diseases and conditions, particularly cardiovascular disease and cancer. To mitigate these risks, quitting smoking is of the utmost importance. This article focuses on reducing tobacco consumption by law enforcement officers in New York.

Tobacco and the health care industry.

The 1964 US Surgeon General's report was the first from the medical profession to document tobacco as a cause of cancers and other serious illnesses. Over the next 40 years, numerous health care groups have worked to decrease tobacco use and lower the associated morbidity and mortality. Registered nurses are the largest group of health care providers and have one of the highest rates of smoking among health care professionals. As such, registered nurses are an important population to target and treat for nicotine addiction. Hospital-based tobacco control programs can provide nurses and other health care professionals with convenient on-site treatment. The chronic care model provides a useful framework for enhancing tobacco control activities and improving outcomes.