Outcomes after decrease in hypothermia usage for out of Hospital Cardiac arrest after targeted temperature management study.

OBJECTIVE: Evaluate trends in targeted temperature management with regards to temperature selection, its effect on neurologic outcomes at discharge, and compare this with recent large randomized controlled trial outcomes. DESIGN: Retrospective cohort study between January 2010 and December 2019. SETTING: Single large tertiary academic community hospital. PATIENTS: 634 adult non-traumatic patients presenting with out of hospital cardiac arrest with persistent comatose state treated with active targeted temperature management. INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS: 473 patients received hypothermia of 33 °C and were compared to 161 patients who received targeted normothermia of 36.5 °C. The primary outcome was Cerebral Performance Category (CPC) at hospital discharge, with levels 1 or 2 considered good outcomes. Mortality, ICU days, ventilator days, and overall hospital stay length were secondary outcomes. Patients receiving T33 had more favorable CPC outcomes when compared to patients receiving T36.5 (OR = 2.4 [1.3, 4.6], p = 0.006). Subgroup analysis of initial non-shockable rhythms demonstrated improved CPC scores (OR = 2.5, p = 0.04), however this was not maintained in the shockable rhythm group. T33 patients had a shorter length of stay. Mortality, ICU days, and ventilator days did not differ between the groups. CONCLUSIONS: Out of hospital cardiac arrest patients with persistent comatose state treated with hypothermia of 33 °C had improved odds of discharge with good neurologic outcomes when compared to those treated with targeted normothermia. This improvement of outcomes appears to have been driven by the improved outcomes in the patients who had presented with non-shockable rhythm.

Utility of applying white blood cell cutoffs to non-diagnostic MRI and ultrasound studies for suspected pediatric appendicitis.

BACKGROUND: Non-contrast magnetic resonance imaging (MRI) and ultrasound studies in pediatric patients with suspected appendicitis are often non-diagnostic. The primary objective of this investigation was to determine if combining these non-diagnostic imaging results with white blood cell (WBC) cutoffs improves their negative predictive values (NPVs). METHODS: A retrospective chart review was conducted including patients ≤18 years old with suspected appendicitis who had MRI performed with or without a preceding ultrasound study in a pediatric emergency department. Imaging results were sorted into 2 diagnostic and 5 non-diagnostic categories. NPVs were calculated for the non-diagnostic MRI and ultrasound categories with and without combining them with WBC cutoffs of <10.0 and <7.5 × 109/L. RESULTS: Of the 612 patients with MRI studies included, 402 had ultrasound studies performed. MRI with incomplete visualization of a normal appendix without secondary signs of appendicitis had an NPV of 97.9% that changed to 98.1% and 98.2% when combined with WBC cutoffs of <10.0 and <7.5, respectively. Ultrasound studies with incomplete visualization of a normal appendix without secondary signs had an NPV of 85.3% that improved to 94.8% and 96.5% when combined with WBC cutoffs of <10.0 and <7.5, respectively. CONCLUSIONS: In pediatric patients with suspected appendicitis, MRI studies with incomplete visualization of a normal appendix without secondary signs have a high NPV that does not significantly change with the use of these WBC cutoffs. In contrast, combining WBC cutoffs with ultrasound studies with the same interpretation identifies low-risk groups.

Even Faster Door-to-Alteplase Times and Associated Outcomes in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: The timely administration of thrombolytic therapy for acute ischemic stroke has been associated with good functional outcomes. Current guidelines recommend alteplase administration within 60 minutes in 75% of eligible patients and within 45 minutes in 50% of patients. There is limited evidence guiding these measures and their effect on outcomes. We report a single-center, retrospective assessment of the safety and efficacy of alteplase treatment within 45 minutes. METHODS: Five hundred and eighty-six patients were treated with alteplase in our emergency departments (EDs) between January 2014 and October 2016; 368 patients were included for analysis. Multivariate regression analysis was used to assess the association between door-to-alteplase (DTA) times and 90-day modified Rankin scale (mRS) scores. Incidence of intracerebral hemorrhage (ICH) was also documented. RESULTS: The median DTA time was 29 minutes versus 64 minutes in the DTA less than or equal to 45 minutes arm and more than 45 minutes arm, respectively. The primary outcome of 90-day mRS 0-1 was achieved in 56% of patients in the less than or equal to 45 minutes group versus 58% in more than 45 minutes group (P = .67). Odds of achieving mRS 0-1 were not significantly impacted by DTA times. In the multivariate regression analysis, patient characteristics associated with achieving mRS 0-1 were: younger age, male sex, not requiring intubation in the ED, and without prior history of hypertension, atrial fibrillation, or stroke. There was no significant difference in rates of ICH for patients less than or equal to 45 minutes versus more than 45 minutes. CONCLUSIONS: Rapid administration of alteplase was not associated with significantly better outcomes nor increased risk of ICH. Conclusions about efficacy are limited due to the retrospective nature of the study, small sample size, and incomplete data points.

Malnutrition and pectoralis muscle index in medical intensive care unit patients: A matched cohort study.

BACKGROUND: Muscle assessment is an important component of nutrition assessment. The Global Leadership Initiative on Malnutrition (GLIM) consortium recently underscored the need for more objective muscle assessment methods in clinical settings. Various assessment techniques are available; however, many have limitations in clinical populations. Computed tomography (CT) scans, obtained for diagnostic reasons, could serve multiple purposes, including muscle measurement for nutrition assessment. Although CT scans of the chest are commonly performed clinically, there is little research surrounding the utility of pectoralis muscle measurements in nutrition assessment. The primary aim was to determine whether CT-derived measures of pectoralis major cross-sectional area (PMA) and quality (defined as mean pectoralis major Hounsfield units [PMHU]) could be used to identify malnutrition in patients who are mechanically ventilated in an intensive care unit (ICU). A secondary aim was to evaluate the relationship between these measures and clinical outcomes in this population. METHODS: A retrospective analysis was conducted on 33 pairs of age- and sex-matched adult patients who are being mechanically ventilated in the ICU. Patients were grouped by nutrition status. Analyses were performed to determine differences in PMA and mean PMHU between groups. Associations between muscle and clinical outcomes were also investigated. RESULTS: Compared with nonmalnourished controls, malnourished patients had a significantly lower PMA (P = 0.001) and pectoralis major (PM) index (PMA/height in m2; P = 0.001). No associations were drawn between PM measures and clinical outcomes. CONCLUSION: These findings regarding CT PM measures lay the groundwork for actualizing the GLIM call to action to validate quantitative, objective muscle assessment methods in clinical settings.

COVID-19 in hospitalized adult patients with sickle cell disease: A 2020 US cohort using Cerner Real-World Data™ (CRWD).

We used Cerner Real-World Data™, representing hospital admission records from 2020, to examine patients with co-occurring sickle cell disease and COVID-19 by discharge disposition grouped as death/hospice versus transfers to other facilities, returned home, or left against medical advice. Among the death/hospice group, we found older age and higher rates of congestive heart failure and diabetes. There were also significant differences in tachypnea, mechanical ventilation, minimum O2 saturation, and length of stay with higher rates in the death/hospice group. Awareness of such factors and associated mortality risks for this population may aid in patient care.

A Pilot Study Using a Collagen/Oxidized Regenerative Cellulose Dressing for Split- Thickness Skin Graft Donor Sites to Reduce Pain and Bleeding Complications.

BACKGROUND: Standardized treatment of split-thickness skin graft (STSG) donor sites is not established. Bleeding can necessitate premature dressing changes, interrupting the healing process and increasing pain. PURPOSE: A collagen/oxidized regenerated cellulose (C/ORC) dressing was used on the donor site. The authors hypothesized that the collagen matrix could decrease bleeding-related complications, reduce pain, and foster epithelialization. METHODS: The C/ORC matrix was applied to the donor site after hemostasis was achieved. Dressings were removed between postoperative days 4 and 7, and the patients' pain levels, bleeding complications, and percentage healed were recorded. RESULTS: Thirty-nine patients were treated with the C/ORC donor site dressing. Of these, 35 patients (89.7%) were receiving at least prophylactic anticoagulation, and no bleeding complications were recorded. The average area of donor sites was 123.8 cm2 (range, 20-528 cm2). Utilizing the Numerical Rating Scale, 25 patients (64.1%) reported no pain with dressing removal while 5 (12.8%) reported a decrease in pain. The percentage of epithelialization as assessed by treating clinician was at least equivalent to other modalities. CONCLUSIONS: The application of a C/ORC matrix to STSG donor wound sites resulted in no bleeding complications and excellent pain control while promoting epithelialization in the patients studied. Following this study, the C/ORC dressing has been incorporated into the authors' standard protocol.

Right Patient, Right Place, Right Time : Field Triage and Transfer to Level I Trauma Centers.

INTRODUCTION: This study sought to compare outcomes of trauma patients taken directly from the field to a Level I trauma center (direct) versus patients that were first brought to a Level III trauma center prior to being transferred to a Level I (transfer) within our inclusive Delaware trauma system. METHODS: A retrospective review of the Level I center's trauma registry was performed using data from 2013 to 2017 for patients brought to a single Level I trauma center from 2 surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. RESULTS: When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared with direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (odds ratio [OR] 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality (P < .001). ISS was predictive of increased risk of mortality (P < .001), increased LOS (P < .001), and craniotomy (P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred (P < .001). DISCUSSION: Delays in the presentation to our Level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.

Right Patient, Right Place, Right Time: Field Triage and Transfer to Level I Trauma Centers.

INTRODUCTION: This study sought to compare the outcomes of trauma patients taken directly from the field to a level I trauma center (direct) versus patients that were first brought to a level III trauma center prior to being transferred to a level I (transfer) within our inclusive Delaware trauma system. METHODS: A retrospective review of the level I center's trauma registry was performed using data from 2013 to 2017 for patients brought to a single level I trauma center from two surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. RESULTS: When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared to direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (OR 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality (P < .001). ISS was predictive of increased risk of mortality (P < .001), increased LOS (P < .001), and craniotomy (P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred (P < .001). DISCUSSION: Delays in presentation to our level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.

Health Care Needs of Homeless Older Adults:: Examining the Needs of a Senior Center Cohort.

OBJECTIVES: To assess the medical status and health care needs of Wilmington's largest accessible group of homeless elders located at St. Patrick's Center in order to identify areas for improvement of medical screening, preventive health care delivery, and disease management. METHODS: A cross sectional study was conducted between December 2016 and August 2018 at St. Patrick's center in Wilmington, DE. Utilizing a structured health needs assessment, 64 unique individuals aged 50 years and older were interviewed. Descriptive statistics were used to compare data from homeless older adults with data from non-homeless older adults. RESULTS: Of the 64 total subjects, 17 self-reported as homeless at the time of interviewing. High rates of depressive and cognitive impairment symptoms were self-reported in both homeless and non-homeless participants. When compared to the non-homeless group at St. Patrick's Center, the homeless cohort was less likely to have received a non-acute assessment (such as a routine physical exam/well check-up) or a routine dental cleaning/x-ray within the past year. Tobacco and alcohol use and were frequently self-reported by homeless and non-homeless respondents and were more frequent in the homeless group. The homeless individuals were more likely to have engaged in illicit drug use. Overall, more than 90% of the subjects had some form of health insurance coverage. The most frequently cited reasons for lack of healthcare were inability to afford co-payments/deductibles and lack of transportation. CONCLUSIONS: To address the health care needs of this population, new programs to improve care should focus on facilitating access to services which address areas of deficiency. This group of older adults has benefited from a range of available services that reflect the work of a staff aware of their medical needs, as indicated by the high rate of insured individuals. Licit and illicit substance use assessment and treatment and dental screening remain areas of need for the homeless older adults interviewed in this study. The high rates of depression and cognitive impairment in both the homeless and non-homeless older adult groups suggest the need for further services in these areas as well. Access to care may be improved by addressing concerns regarding co-payments, deductibles, and transportation to care.

Improving Tracheostomy Decannulation Rate In Trauma Patients.

OBJECTIVE: Identify the effect of a multidisciplinary tracheostomy decannulation protocol (TDP) in the trauma population. DESIGN: Single center retrospective review. SETTING: American College of Surgeons Level 1 Trauma Center; large academic associated community hospital. PATIENTS: Adult trauma patients who required a tracheostomy. INTERVENTIONS: A TDP empowering respiratory therapists to move patients towards tracheostomy decannulation (TD). MEASUREMENTS: TD rate, time to TD, length of stay, reintubation and recannulation rates. MAIN RESULTS: A total of 252 patients met inclusion criteria during the study period with 134 presenting after the TDP was available. Since the TDP was implemented, patients managed by the TDP had a 50% higher chance of TD during the hospital stay (p<0.001). The time to TD was 1 day shorter with the TDP (p=0.54). There was no difference in time to discharge after ventilator liberation (p=0.91) or in discharge disposition (p=0.66). When comparing all patients, the development of a TDP, regardless if a patient was managed by the TDP, resulted in an 18% higher chance of TD (p=0.003). Time to TD was 5 days shorter in the post intervention period (p=0.07). There was no difference in discharge disposition (p=0.88) but the time to discharge after ventilator liberation was shorter post protocol initiation (p=0.04). CONCLUSIONS: In a trauma population, implementation of a TDP significantly improves TD rates during the same hospital stay. A larger population will be required to identify patient predictive factors for earlier successful TD.

Ticagrelor Versus Clopidogrel in Black Patients With Stable Coronary Artery Disease: Prospective, Randomized, Open-Label, Multiple-Dose, Crossover Pilot Study.

BACKGROUND: The burden of coronary artery disease (CAD) is high in blacks, highlighting the need for clinical research of antiplatelet agents in this population. We sought to evaluate platelet reactivity during loading and maintenance dosing of ticagrelor versus clopidogrel, and the pharmacokinetic profile of ticagrelor and its metabolite AR-C124910XX, in black patients with stable CAD taking low-dose aspirin (acetylsalicylic acid). METHODS AND RESULTS: In a multicenter, randomized, open-label, crossover study, 34 blacks with stable CAD receiving acetylsalicylic acid 75 to 100 mg/d were randomized to clopidogrel (600 mg, then 75 mg QD for 7-9 days) or ticagrelor (180 mg, then 90 mg BID for 7-9 days). After washout 10 to 14 days, patients switched regimens. The primary end point was platelet reactivity 2 hours post loading dose (P2Y12 reactivity units [PRU] measured by the VerifyNow assay). Least-squares mean PRU at 2 hours post loading dose was lower with ticagrelor (27.6) versus clopidogrel (211.2); least-squares mean difference was -183.6 (95% confidence interval, -213.9 to -153.3; P<0.001). At all time points, the least-squares mean PRU was significantly lower, and the percent reduction in PRU from baseline was statistically greater, with ticagrelor versus clopidogrel. At 2 hours post dose, the prevalence of high on-treatment platelet reactivity (≥208 PRU) was lower with ticagrelor (0%) than with clopidogrel (57.1%). Pharmacokinetic profiles of ticagrelor and AR-C124910XX were consistent with previous reports in stable CAD populations. CONCLUSIONS: In black patients with stable CAD receiving low-dose acetylsalicylic acid, ticagrelor provided a faster onset and greater degree of platelet inhibition than clopidogrel. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01523392.

Lipid and apolipoprotein ratios: association with coronary artery disease and effects of rosuvastatin compared with atorvastatin, pravastatin, and simvastatin.

Plasma lipid and apolipoprotein ratios that include both an atherogenic and an antiatherogenic lipid component (eg, total cholesterol/high-density lipoprotein [HDL] cholesterol ratio, low-density lipoprotein [LDL] cholesterol/HDL cholesterol ratio, non-HDL cholesterol/HDL cholesterol ratio, and apolipoprotein [apo] B/apo A-I ratio) have been found to be strong predictors of coronary artery disease (CAD) risk. Three trials that compared the effects of rosuvastatin 10 mg versus atorvastatin 10 mg and 2 trials that compared the effects of rosuvastatin 10 mg versus simvastatin 20 mg and pravastatin 20 mg on lipid ratios in patients with hypercholesterolemia were prospectively designed for pooled analysis. At 12 weeks, in the 3-trial pooled analysis, rosuvastatin 10 mg (n = 389) showed significantly greater reductions in all 4 lipid ratios compared with atorvastatin 10 mg (n = 393) (p <0.001). The mean percent reduction from baseline in the LDL cholesterol/HDL cholesterol ratio was 51% in patients treated with rosuvastatin 10 mg versus 39% in patients treated with atorvastatin 10 mg. In the 2-trial pooled analysis, treatment with rosuvastatin 10 mg (n = 226) also resulted in significantly greater reductions in all 4 lipid ratios compared with both simvastatin 20 mg (n = 249) and pravastatin 20 mg (n = 252) (p <0.001). Mean percent reductions from baseline in the LDL cholesterol/HDL cholesterol ratio were 52%, 39%, and 30% for rosuvastatin 10 mg, simvastatin 20 mg, and pravastatin 20 mg, respectively, in these 2 trials.

Effects of rosuvastatin versus atorvastatin, simvastatin, and pravastatin on non-high-density lipoprotein cholesterol, apolipoproteins, and lipid ratios in patients with hypercholesterolemia: additional results from the STELLAR trial.

BACKGROUND: Non-high-density lipoprotein cholesterol (HDL-C), apolipoprotein (apo) B, and lipid and apolipoprotein ratios that include both atherogenic and antiatherogenic lipid components have been found to be strong predictors of coronary heart disease risk. OBJECTIVE: The goal of this study was to examine prospectively the effects of rosuvastatin, atorvastatin, simvastatin, and pravastatin across dose ranges on non-HDL-C, apo B, apo A-I, and total cholesterol (TC):HDL-C, low-density lipoprotein cholesterol (LDL-C):HDL-C, non-HDL-C:HDL-C, and apo B:apo A-I ratios in patients with hypercholesterolemia (LDL-C > or =160 mg/dL and <250 mg/dL and triglycerides <400 mg/dL) in the Statin Therapies for Elevated Lipid Levels compared Across doses to Rosuvastatin (STELLAR) trial. METHODS: In this randomized, Multicenter, parallel-group, open-label trial (4522IL/0065), patients > or =18 years of age received rosuvastatin 10, 20, 40, or 80 mg; atorvastatin 10, 20, 40, or 80 mg; simvastatin 10, 20, 40, or 80 mg; or pravastatin 10, 20, or 40 mg for 6 weeks. Pairwise comparisons were prospectively planned and performed between rosuvastatin 10, 20, and 40 mg and milligram-equivalent or higher doses of comparators. RESULTS: A total of 2268 patients were randomized to the rosuvastatin 10- to 40-mg, atorvastatin, simvastatin, and pravastatin groups. Fifty-one percent of patients were women, the mean (SD) age was 57 (12) years, and 19% had a documented history of atherosclerotic disease. Over 6 weeks, rosuvastatin significantly reduced non-HDL-C, apo B, and all lipid and apolipoprotein ratios assessed, compared with milligram-equivalent doses of atorvastatin and milligram-equivalent or higher doses of simvastatin and pravastatin (all, P < 0.002). Rosuvastatin reduced non-HDL-C by 42.0% to 50.9% compared with 34.4% to 48.1% with atorvastatin, 26.0% to 41.8% with simvastatin, and 18.6% to 27.4% with pravastatin. Rosuvastatin reduced apo B by 36.7% to 45.3% compared with 29.4% to 42.9% with atorvastatin, 22.2% to 34.7% with simvastatin, and 14.7% to 23.0% with pravastatin. The highest increase in apo A-I (8.8%) was observed in the rosuvastatin 20-mg group, and this increase was significantly greater than in the atorvastatin 40-mg and 80-mg groups (both, P < 0.002). CONCLUSION: Rosuvastatin 10 to 40 mg was more efficacious in improving the lipid profile of patients with hypercholesterolemia than milligram-equivalent doses of atorvastatin and milligram-equivalent or higher doses of simvastatin and pravastatin.