A Neurosurgical Readmissions Reduction Program in an Academic Hospital Leveraging Machine Learning, Workflow Analysis, and Simulation.

BACKGROUND: Predicting 30-day hospital readmissions is crucial for improving patient outcomes, optimizing resource allocation, and achieving financial savings. Existing studies reporting the development of machine learning (ML) models predictive of neurosurgical readmissions do not report factors related to clinical implementation. OBJECTIVES: Train individual predictive models with good performance (area under the receiver operating characteristic curve or AUROC > 0.8), identify potential interventions through semi-structured interviews, and demonstrate estimated clinical and financial impact of these models. METHODS: Electronic health records were utilized with five ML methodologies: gradient boosting, decision tree, random forest, ridge logistic regression, and linear support vector machine. Variables of interest were determined by domain experts and literature. The dataset was split divided 80% for training and validation and 20% for testing randomly. Clinical workflow analysis was conducted using semi-structured interviews to identify possible intervention points. Calibrated agent-based models (ABMs), based on a previous study with interventions, were applied to simulate reductions of the 30-day readmission rate and financial costs. RESULTS: The dataset covered 12,334 neurosurgical intensive care unit (NSICU) admissions (11,029 patients); 1,903 spine surgery admissions (1,641 patients), and 2,208 traumatic brain injury (TBI) admissions (2,185 patients), with readmission rate of 13.13, 13.93, and 23.73%, respectively. The random forest model for NSICU achieved best performance with an AUROC score of 0.89, capturing potential patients effectively. Six interventions were identified through 12 semi-structured interviews targeting preoperative, inpatient stay, discharge phases, and follow-up phases. Calibrated ABMs simulated median readmission reduction rates and resulted in 13.13 to 10.12% (NSICU), 13.90 to 10.98% (spine surgery), and 23.64 to 21.20% (TBI). Approximately $1,300,614.28 in saving resulted from potential interventions. CONCLUSION: This study reports the successful development and simulation of an ML-based approach for predicting and reducing 30-day hospital readmissions in neurosurgery. The intervention shows feasibility in improving patient outcomes and reducing financial losses.

Predictors of Metformin Failure: Repurposing Electronic Health Record Data to Identify High-Risk Patients.

CONTEXT: Metformin is the first-line drug for treating diabetes but has a high failure rate. OBJECTIVE: To identify demographic and clinical factors available in the electronic health record (EHR) that predict metformin failure. METHODS: A cohort of patients with at least 1 abnormal diabetes screening test that initiated metformin was identified at 3 sites (Arizona, Mississippi, and Minnesota). We identified 22 047 metformin initiators (48% female, mean age of 57 ± 14 years) including 2141 African Americans, 440 Asians, 962 Other/Multiracial, 1539 Hispanics, and 16 764 non-Hispanic White people. We defined metformin failure as either the lack of a target glycated hemoglobin (HbA1c) (<7%) within 18 months of index or the start of dual therapy. We used tree-based extreme gradient boosting (XGBoost) models to assess overall risk prediction performance and relative contribution of individual factors when using EHR data for risk of metformin failure. RESULTS: In this large diverse population, we observed a high rate of metformin failure (43%). The XGBoost model that included baseline HbA1c, age, sex, and race/ethnicity corresponded to high discrimination performance (C-index of 0.731; 95% CI 0.722, 0.740) for risk of metformin failure. Baseline HbA1c corresponded to the largest feature performance with higher levels associated with metformin failure. The addition of other clinical factors improved model performance (0.745; 95% CI 0.737, 0.754, P < .0001). CONCLUSION: Baseline HbA1c was the strongest predictor of metformin failure and additional factors substantially improved performance suggesting that routinely available clinical data could be used to identify patients at high risk of metformin failure who might benefit from closer monitoring and earlier treatment intensification.

Endocarditis bacteriana por Escherichia coli / Bacterial endocarditis due to Escherichia coli

Introducción: La endocarditis bacteriana es una enfermedad poco frecuente, ocasionada en la mayor parte de casos por organismos gram positivos, como estafilococos y estreptococos, seguido por organismos del grupo HACEK y raramente por gram negativos no HACEK. Su incidencia es baja, pero se relaciona con una alta mortalidad; existen diversos factores de riesgo asociados: edad avanzada, sexo femenino, antecedente de cirugías cardiacas, válvulas protésicas, uso de catéteres venosos centrales o urinarios. Objetivo: Describir la evidencia disponible sobre endocarditis bacteriana por Escherichia coli. Desarrollo: Se describe el caso de un paciente adulto mayor, sin antecedentes quirúrgicos cardíacos, que presenta cuadro de desorientación, astenia, adinamia, elevación de la temperatura corporal, asociados a infección urinaria, que luego de recibir piperacilina-tazobactam por 7 días, persiste con alzas térmicas. Hemocultivos confirman bacteriemia por Escherichia coli y en ecocardiograma transesofágico se logra la visualización de una vegetación a nivel de válvula aórtica nativa. El paciente recibió tratamiento antibiótico con cefalosporina de tercera generación por 30 días, con mejoría clínica, eco transesofágico de control sin vegetaciones, ni necesidad inmediata de tratamiento quirúrgico. Conclusiones: La sospecha clínica de endocarditis es importante en el momento de solicitar exámenes diagnósticos e interpretar sus resultados(AU)

Introduction: Bacterial endocarditis is a rare disease, caused in most cases by gram-positive organisms, such as staphylococci and streptococci, followed by HACEK group organisms and rarely by non-HACEK gram-negative organisms. Its incidence is low, but it is related to high mortality; there are several associated risk factors: advanced age, female sex, history of heart surgery, prosthetic valves, use of central venous or urinary catheters. Objective: To describe the available evidence on bacterial endocarditis due to Escherichia coli. Case report: We describe the case of an elderly patient, without a history of cardiac surgery, who showed disorientation, asthenia, adynamia, elevation of body temperature, associated with urinary infection, persisting after taken piperacillin-tazobactam for 7 days with temperature rises. Blood cultures confirm Escherichia coli bacteremia and transesophageal echocardiography exhibited vegetation at the native aortic valve level. The patient received antibiotic treatment with third-generation cephalosporin for 30 days, with clinical improvement, echo transesophageal control with no vegetations, and no immediate need for surgical treatment. Conclusions: The clinical suspicion of endocarditis is vital when requesting diagnostic tests and interpreting their results(AU)

Do Hospitals Providing Telehealth in Emergency Departments Have Lower Emergency Department Costs?

Background: Since 2003, the University of Mississippi Medical Center has operated a robust telehealth emergency department (ED) network, TelEmergency, which enhances access to emergency medicine-trained physicians at participating rural hospitals. TelEmergency was developed as a cost-control measure for financially constrained rural hospitals to improve access to quality, emergency care. However, the literature remains unclear as to whether ED telehealth services can be provided at lower costs compared with traditional in-person ED services. Introduction: Our objective was to empirically determine whether TelEmergency was associated with lower ED costs at rural hospitals when compared with similar hospitals without TelEmergency between 2010 and 2017. Materials and Methods: A panel of data for 2010-2017 was constructed at the hospital level. Hospitals with TelEmergency (n = 14 hospitals; 112 hospital-years) were compared with similar hospitals that did not use TelEmergency from Arkansas, Georgia, Mississippi, and South Carolina (n = 102; 766 hospital-years), matched using Coarsened Exact Matching. The relationship between total ED costs and treatment (e.g., participation in TelEmergency) was predicted using generalized estimating equations with a Poisson distribution, a log link, an exchangeable error term, and robust standard errors. Results: After controlling for ownership type, critical access hospital status, year, and size, TelEmergency was associated with an estimated 31.4% lower total annual ED costs compared with similar matched hospitals that did not provide TelEmergency. Conclusions: TelEmergency utilization was associated with significantly lower total annual ED costs compared with similarly matched hospitals that did not utilize TelEmergency. These findings suggest that access to quality ED care in rural communities can occur at lower costs.

Continuity of Care for Patients with Obesity-Associated Chronic Conditions: Protocol for a Multisite Retrospective Cohort Study.

BACKGROUND: Obesity affects nearly half of adults in the United States and is contributing substantially to a pandemic of obesity-associated chronic conditions such as type 2 diabetes, hypertension, and arthritis. The obesity-associated chronic condition pandemic is particularly severe in low-income, medically underserved, predominantly African-American areas in the southern United States. Little is known regarding the impact of geographic, income, and racial disparities in continuity of care on major health outcomes for patients with obesity-associated chronic conditions. OBJECTIVE: The aim of this study is to assess, among patients with obesity-associated chronic conditions, and within this group, patients with type 2 diabetes, (1) whether continuity of care is associated with lower overall and potentially preventable emergency department and hospital utilization, (2) the effect of geographic, income, and racial disparities on continuity of care and on health care utilization, (3) whether continuity of care particularly protects individuals at risk for disparities from adverse health outcomes, and (4) whether characteristics of health systems are associated with higher continuity of care and better outcomes. METHODS: Using 2015-2018 data from 4 practice-based research networks participating in the Southern Obesity and Diabetes Coalition, we will conduct a retrospective cohort analysis and distributed meta-analysis. Patients with obesity-associated chronic conditions and with type 2 diabetes will be assessed within each health system, following a standardized study protocol. The primary study outcomes are overall and preventable emergency department visits and hospitalizations. Continuity of care will be calculated at the facility level using a modified version of the Bice-Boxerman continuity of care index. Race will be assessed using electronic medical record data. Residence in a low-income area or a health professional shortage area respectively will be assessed by linking patient residence ZIP codes to the Centers for Medicare & Medicaid Services database. RESULTS: In 4 regional health systems across Tennessee, Mississippi, Louisiana, and Arkansas, a total of 53 adult hospitals were included in the study. A total of 147,889 patients with obesity-associated chronic conditions who met study criteria were identified in these health systems, of which 45,453 patients met the type 2 diabetes criteria for inclusion. Results are expected by the end of 2020. CONCLUSIONS: This study should reveal whether health system efforts to increase continuity of care for patients with obesity and diabetes have potential to improve outcomes and reduce costs. Analyzing disparities in continuity of care and their effect on major health outcomes can help demonstrate how to improve care and use of health care resources for vulnerable patients with obesity-associated chronic conditions, and within this group, patients with type 2 diabetes. Better understanding of the association between continuity and health care utilization for these vulnerable populations will contribute to the development of higher-value health systems in the southern United States. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/20788.

Maternal Antiasthma Simplified Herbal Medicine Intervention therapy prevents airway inflammation and modulates pulmonary innate immune responses in young offspring mice.

BACKGROUND: Maternal asthma is a risk factor for asthma in offspring; however, transmission of the risk for allergic asthma without direct offspring sensitization has not been explored. OBJECTIVE: To determine whether offspring from mothers with ovalbumin (OVA)-sensitized asthma would develop airway disease at first-ever exposure to OVA and whether preconception maternal treatment with the Antiasthma Simplified Herbal Medicine Intervention (ASHMI) or dexamethasone (DEX) could modify this risk in offspring. METHODS: Female BALB/c mice (F0) with OVA-induced asthma were generated using established protocols. Mice with asthma were treated with ASHMI, DEX, or water for 6 to 7 weeks. Naive mice served as controls. Subsequently, mice were mated. Twelve-day-old F1 offspring received 3 consecutive intranasal low- or high-dose OVA exposures without sensitization. Forty-eight hours later, airway inflammation, mucus hypersecretion, serum antibodies, and cytokines were evaluated. RESULTS: Offspring from OVA-sensitized mothers, but not naive mothers, showed eosinophilic and neutrophilic airway inflammation, and mucus hyperplasia after OVA exposure and he presence of OVA-specific IgG1 and IgG2a. Offspring of ASHMI- and DEX-treated mothers showed decreased airway inflammation and mucus hypersecretion after low-dose OVA (P < .05-.001 for the 2 comparisons vs offspring of OVA/Sham mothers). Offspring of ASHMI-treated, but not DEX-treated, mothers were protected after the high-dose OVA challenge (P < .05-.01 vs offspring OVA/Sham). Maternal ASHMI therapy was associated with increased IgG2a (P < .01 vs offspring of OVA/Sham mothers) and decreased bronchoalveolar lavage fluid CXCL-1 and eotaxin-1 levels (P < .01 and P < .05, respectively, vs offspring of OVA/Sham mothers). CONCLUSION: Offspring of mothers with OVA-induced asthma developed airway inflammation and mucus to first-ever OVA exposure without prior sensitization. Maternal therapy with ASHMI was superior to DEX in decreasing offspring susceptibility to airway disease and could be a strategy to lower asthma prevalence.

Chinese herbal extracts of Rubia cordifolia and Dianthus superbus suppress IgE production and prevent peanut-induced anaphylaxis.

BACKGROUND: Peanut allergy is characterized by increased levels of peanut-specific IgE in the serum of most patients. Thus, the most logical therapy would be to inhibit the IgE production by committed B-cells. This study aims to investigate the unreported anti-IgE effects of Chinese herbal extracts of Rubia cordifolia (Qiancao) and Dianthus superbus (Qumai). METHODS: Seventy herbal extracts were tested for their ability to reduce IgE secretion by a human B-cell line. Those with the lowest inhibitory concentration 50 (IC50) values were tested in a mouse model of peanut-anaphylaxis. Anaphylactic scores, body temperature, plasma histamine and peanut-specific-immunoglobulins were determined. RESULTS: Rubia cordifolia and Dianthus superbus inhibited the in vitro IgE production by a human B-cell line in a dose-dependent manner and the in vivo IgE production in a murine model of peanut allergy without affecting peanut-specific-IgG1 levels. After challenge, all mice in the sham groups developed anaphylactic reactions and increased plasma histamine levels. The extract-treated mice demonstrated significantly reduced peanut-triggered anaphylactic reactions and plasma histamine levels. CONCLUSION: The extracts of Rubia cordifolia and Dianthus superbus inhibited the IgE production in vivo and in vitro as well as reduced anaphylactic reactions in peanut-allergic mice, suggesting potentials for allergy treatments.

Maternal peanut consumption provides protection in offspring against peanut sensitization that is further enhanced when co-administered with bacterial mucosal adjuvant.

The aims of the present study were to assess whether protection against peanut (PN) sensitization can be conferred by maternal PN consumption alone and if so, whether protection was increased by mucosal adjuvant co-administration. Mice were fed with low dose of either PN or PN with cholera toxin (CT) preconceptionally, and during pregnancy and lactation. Offspring serum PN-specific immunoglobulins and cellular responses by splenocytes and mesenteric lymph node (MLN) cells were determined after an active PN sensitization protocol. Milk was collected from lactating mothers of 11-21-day-old pups for evaluation of PN-specific immunoglobulin levels. We found that offspring of PN fed mothers exhibited lower PN-specific IgE levels and reduced PN-stimulated splenocyte and MLN cells cytokine secretion than offspring of non PN fed mothers. CT co-administration with PN enhanced these responses.. Milk from mothers fed PN and CT, but not PN alone preconceptionally and during pregnancy and lactation contained markedly and significantly increased levels of both peanut-specific IgG2a and IgA. Our study demonstrated that maternal feeding of PN alone had a protective effect against PN sensitization of the progeny, which was enhanced by co-administration of a mucosal adjuvant. Increased levels of PN-specific IgG2a and/or IgA in milk were seen when PN and CT were administered together, suggesting that transmission of maternal immunoglobulins may play a role in the observed protection.

Observaciones preliminares sobre comportamiento prenatal y postnatal de Rattus rattus var. norvegicus (Lineo 1758) en el laboratorio / Preliminary observations on prenatal and postnatal behavior of Rattus rattus var. norvegicus (Linnaeus 1758) in the laboratory

Con el objeto de lograr entrenamiento en la observación de roedores silvestres traídos al laboratorio, se llevó a cabo un estudio del comportamiento durante la preñez y la lactancia de Rattus rattus var. norvegicus (Linneo 1758). Se observó que la agresividad de la madre aumentó conforme iba acercándose el parto, el cual se produjo al décimo séptimo día de gestación. Desde que las crías nacieron, la madre se mostró muy celosa y protectora; y nunca rechazó a sus crías a pesar de que estas eran manipuladas diariamente, para evaluar su peso y sus medidas de longitud cabeza - cuerpo. No se presentó canibalismo. El éxito reproductivo fue del 100% pues todas las crías llegaron a la adultez. Para el peso se encontró que las diferencias sexuales se hacen significativas a partir del día 29 (p=0.006) mientras que para la longitud cabeza - cuerpo ocurre a partir del día 32 (p=0.012). El destete se produjo el día 30.

The present research work was conducted with the objective of acquiring training in the observation of wild rats brought to laboratory conditions. It consisted in observing pre and postnatal behavior in Rattus rattus var. norvegicus (Linneo 1758). The fact the mother's aggressiveness increased with the arrival of parturition, event that ocurred on the 17th day of gestation was observed. Once the pups were born, the mother showed herself protective and careful. She never rejected her pups even when they were manipulated daily to assess their weight and head - body size development. Cannibalism was not observed. The reproductive success was a 100% considering the fact that all pups reached adulthood. In relation to weight and head - body size, it eas found that sexual differences became significant around day 29 th (p=0.006) and day 32th (p=0.012), respectively. Weaning ocurred on day 30 th.