Spectrum of prevalent cardiovascular diseases in urban Port-au-Prince, Haiti: a population-based cross-sectional study.

Background: Eighty percent of global cardiovascular disease (CVD) is projected to occur in low- and middle -income countries (LMICs), yet local epidemiological data are scarce. We provide the first population-based, adjudicated CVD prevalence estimates in Port-au-Prince, Haiti to describe the spectrum of heart disease and investigate associated risk factors. Methods: Demographic, medical history, clinical, imaging and laboratory data were collected among adults recruited using multistage random sampling from 2019 to 2021. Prevalent CVD (heart failure, stroke, ischemic disease) were adjudicated using epidemiological criteria similar to international cohorts. Multivariable Poisson regressions assessed relationships between risk factors and prevalent CVD. Findings: Among 3003 participants, median age was 40 years, 58.1% were female, 70.2% reported income <1 USD/day, and all identified as Black Haitian. CVD age-adjusted prevalence was 14.7% (95% CI 13.3%, 16.5%), including heart failure (11.9% [95% CI 10.5%, 13.5%]), stroke (2.4% [95% CI 1.9%, 3.3%]), angina (2.1% [95% CI 1.6%, 2.9%]), myocardial infarction (1.0% [95% CI 0.6%, 1.8%]), and transient ischemic attack (0.4% [95% CI 0.2%, 1.0%]). Among participants with heart failure, median age was 57 years and 68.5% of cases were among women. The most common subtype was heart failure with preserved ejection fraction (80.4%). Heart failure was associated with hypertension, obesity, chronic kidney disease, depression, and stress. Interpretation: Early-onset heart failure prevalence is alarmingly high in urban Haiti and challenge modelling assumptions that ischemic heart disease and stroke dominate CVDs in LMICs. These data underscore the importance of local population-based epidemiologic data within LMICs to expedite the selection and implementation of evidence-based cardiovascular health policies targeting each country's spectrum of heart disease. Funding: This study was funded by NIH grants R01HL143788, D43TW011972, and K24HL163393, clinicaltrials.govNCT03892265.

Evidence for validity of the epidemic-pandemic impacts inventory (brief healthcare module): Internal structure and association with other variables.

The COVID-19 pandemic has subjected healthcare workers to enormous stress. Measuring the impact of this public health emergency is essential to developing strategies that can effectively promote resilience and wellness. The Epidemic-Pandemic Impacts Inventory Supplemental Healthcare Module-Brief Version (EPII-SHMb) was developed to measure impacts among occupational cohorts serving on the front lines of healthcare. While this instrument has been utilized in COVID-19 related studies, little is known about its psychometric properties. This study collects evidence for validity of the EPII-SHMb by evaluating its internal structure and how its scores associate with other variables. Physicians and nursing staff across a large New York health system were cross-sectionally surveyed using an online questionnaire between June and November 2020. Exploratory factor analysis resulted in a 3-factor solution, identifying factors Lack of Workplace Safety (7 items), Death/Dying of Patients (3 items), and Lack of Outside Support (2 items). Internal consistency was high overall and within physician/nursing and gender subgroups (Cronbach's alpha: 0.70 - 0.81). Median scores on Death/Dying of Patients were higher among those who directly cared for COVID-19 patients or worked in COVID-19 hospital units. These results are promising. Additional studies evaluating other dimensions of validity are necessary.

Extreme Food Insecurity and Malnutrition in Haiti: Findings from a Population-Based Cohort in Port-au-Prince, Haiti.

Haiti is one of the most food-insecure (FIS) nations in the world, with increasing rates of overweight and obesity. This study aimed to characterize FIS among households in urban Haiti and assess the relationship between FIS and body mass index (BMI) using enrollment data from the Haiti Cardiovascular Disease Cohort Study. FIS was characterized as no/low, moderate/high, and extreme based on the Household Food Security Scale. Multinomial logistic generalized estimating equations were used to evaluate the association between FIS categories and BMI, with obesity defined as BMI ≥ 30 kg/m2. Among 2972 participants, the prevalence of moderate/high FIS was 40.1% and extreme FIS was 43.7%. Those with extreme FIS had higher median age (41 vs. 38 years) and were less educated (secondary education: 11.6% vs. 20.3%) compared to those with no/low FIS. Although all FIS categories had high obesity prevalence, those with extreme FIS compared to no/low FIS (15.3% vs. 21.6%) had the lowest prevalence. Multivariable models showed an inverse relationship between FIS and obesity: moderate/high FIS (OR: 0.77, 95% CI: 0.56, 1.08) and extreme FIS (OR: 0.58, 95% CI: 0.42, 0.81) versus no/low FIS were associated with lower adjusted odds of obesity. We found high prevalence of extreme FIS in urban Haiti in a transitioning nutrition setting. The inverse relationship between extreme FIS and obesity needs to be further studied to reduce both FIS and obesity in this population.

High prevalence of obesity among women in urban Haiti: Findings from a population-based cohort.

Introduction: Obesity is associated with increased risk of non-communicable diseases and death and is increasing rapidly in low- and middle-income countries, including Haiti. There is limited population-based data on body mass index (BMI) and waist circumference (WC) and associated risk factors in Haiti. This study describes BMI and WC, and factors associated with obesity using a population-based cohort from Port-au-Prince. Methods: Baseline sociodemographic and clinical data were collected from participants in the Haiti CVD Cohort Study between March 2019 and August 2021. Weight was categorized by BMI (kg/m2) with obesity defined as ≥30 kg/m2. Abdominal obesity was defined using WC cutoffs of ≥80 cm for women and ≥94 cm for men based on WHO guidelines. Sociodemographic and behavioral risk factors, including age, sex, educational attainment, income, smoking status, physical activity, fat/oil use, daily fruit/vegetable consumption, and frequency of fried food intake were assessed for their association with obesity using a Poisson multivariable regression. Results: Among 2,966 participants, median age was 41 years (IQR: 28-55) and 57.6% were women. Median BMI was 24.0 kg/m2 (IQR: 20.9-28.1) and 508 (17.1%) participants were obese. Women represented 89.2% of the population with BMI ≥30 kg/m2. A total of 1,167 (68.3%) women had WC ≥80 cm and 144 (11.4%) men had WC ≥94 cm. BMI ≥30 kg/m2 was significantly more prevalent among women than men [PR 5.7; 95% CI: (4.3-7.6)], those 40-49 years compared to 18-29 years [PR 3.3; 95% CI: (2.4-4.6)], and those with income >10 USD per day compared to ≤1 USD [PR 1.3; 95% CI: (1.0-1.6)]. There were no significant associations with other health and behavioral risk factors. Discussion: In Haiti, women have an alarming 6-fold higher obesity prevalence compared to men (26.5 vs. 4.3%) and 89.2% of participants with obesity were women. Abdominal obesity was high, at 44.3%. Haiti faces a paradox of an ongoing national food insecurity crises and a burgeoning obesity epidemic. Individual, social, and environmental drivers of obesity, especially among women, need to be identified.

Assessing the Feasibility and Effectiveness of a Linkage Into Mental Health Care Program for Adults Affected by Hurricane Sandy.

OBJECTIVE: Research indicates that greater exposure to Hurricane Sandy is associated with increased mental health difficulties. This study examined whether Project Restoration, a program that linked adults into mental health care (L2C), was effective in reducing post-Sandy mental health difficulties as compared to a cohort of adults matched on mental health difficulties that were not linked into post-Sandy mental health care. METHODS: Project Restoration participants (n = 52) with elevated self-reported mental health difficulties had the option to enroll into L2C. Project LIGHT (n = 63) used similar methodologies but did not have a L2C component and served as the matched control group. RESULTS: Multivariable modeling showed significant decreases in all mental health difficulties except for depression in the Project Restoration group, whereas there were no significant decreases in LIGHT. The decrease in anxiety from baseline to follow-up was significantly greater for Project Restoration as compared to LIGHT. CONCLUSION: Findings confirm the powerful impact community outreach and treatment have on reducing mental health difficulties after a disaster.

Predictors of Emergency Department Opioid Use Among Adolescents and Young Adults.

OBJECTIVE: It is well established that adolescents and young adults are increasingly vulnerable to the effects of early opioid exposures, with the emergency department (ED) playing a critical role in such introduction. Our objective was to identify predictors of ED opioid administration (ED-RX) and prescribing at discharge (DC-RX) among adolescent and young adults using a machine learning approach. METHODS: We conducted a secondary analysis of ED visit data from the National Hospital Ambulatory Medical Care Survey from 2014 to 2018. Visits where patients were aged 10 to 24 years were included. Predictors of ED-RX and DC-RX were identified via machine learning methods. Separate weighted logistic regressions were performed to determine the association between each predictor, and ED-RX and DC-RX, respectively. RESULTS: There were 12,693 ED visits identified within the study time frame, with the majority being female (58.6%) and White (70.7%). Approximately 12.3% of all visits were administered an opioid during the ED visit, and 11.5% were prescribed one at discharge. For ED-RX, the strongest predictors were fracture injury (odds ratio [OR], 5.24; 95% confidence interval [CI], 3.73-7.35) and Southern geographic region (OR, 3.01; 95% CI, 2.14-4.22). The use of nonopioid analgesics significantly reduced the odds of ED-RX (OR, 0.46; 95% CI, 0.37-0.57). Fracture injury was also a strong predictor of DC-RX (OR, 5.91; 95% CI, 4.24-8.25), in addition to tooth pain (OR, 5.47; 95% CI, 3.84-7.69). CONCLUSIONS: Machine learning methodologies were able to identify predictors of ED-RX and DC-RX, which can be used to inform ED prescribing guidelines and risk mitigation efforts among adolescents and young adults.

Mortality of Mechanically Ventilated COVID-19 Patients in Traditional versus Expanded Intensive Care Units in New York.

Rationale: During the first wave of the coronavirus disease (COVID-19) pandemic in New York City, the number of mechanically ventilated COVID-19 patients rapidly surpassed the capacity of traditional intensive care units (ICUs), resulting in health systems utilizing other areas as expanded ICUs to provide critical care. Objectives: To evaluate the mortality of patients admitted to expanded ICUs compared with those admitted to traditional ICUs. Methods: Multicenter, retrospective, cohort study of mechanically ventilated patients with COVID-19 admitted to the ICUs at 11 Northwell Health hospitals in the greater New York City area between March 1, 2020 and April 30, 2020. Primary outcome was in-hospital mortality up to 28 days after intubation of COVID-19 patients. Results: Among 1,966 mechanically ventilated patients with COVID-19, 1,198 (61%) died within 28 days after intubation, 46 (2%) were transferred to other hospitals outside of the Northwell Health system, 722 (37%) survived in the hospital until 28 days or were discharged after recovery. The risk of mortality of mechanically ventilated patients admitted to expanded ICUs was not different from those admitted to traditional ICUs (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.95-1.20; P = 0.28), while hospital occupancy for critically ill patients itself was associated with increased risk of mortality (HR, 1.28; 95% CI, 1.12-1.45; P < 0.001). Conclusions: Although increased hospital occupancy for critically ill patients itself was associated with increased mortality, the risk of 28-day in-hospital mortality of mechanically ventilated patients with COVID-19 who were admitted to expanded ICUs was not different from those admitted to traditional ICUs.

Passive transfer of SARS-CoV-2 antibodies with platelet transfusions.

BACKGROUND: Although over 5000 platelet transfusions occur daily in the United States, the presence of SARS-CoV-2 antibodies in platelet units is not commonly evaluated for. The effects of platelet transfusions with SARS-CoV-2 antibodies remain largely unknown. We evaluated single-donor (apheresis) platelet units for SARS-CoV-2 antibodies and determined if platelet transfusions passively transferred antibodies to seronegative recipients. STUDY DESIGN AND METHODS: We conducted a retrospective analysis as part of a quality assurance initiative during February to March 2021 at a tertiary referral academic center in suburban New York. Platelet units and platelet recipients were evaluated for the presence of SARS-CoV-2 antibodies using the DiaSorin LIASON SARS-CoV-2 S1/S2 IgG assay. There were 47 platelet recipients eligible for study inclusion. The primary outcome was the presence of SARS-CoV-2 spike protein IgG antibodies in the recipient's blood after platelet transfusion. RESULTS: Twenty-three patients received platelets with SARS-CoV-2 spike protein IgG antibodies; 13 recipients had detection of SARS-COV-2 antibodies (56.5%), and 10 recipients did not. The median antibody titer in the platelet units given to the group with passive antibodies detected was significantly higher compared to the median antibody titer in the platelet units given to the group without antibodies detected (median [interquartile range]: 306 AU/ml [132, 400] vs. 96.1 AU/ml [30.6, 186], p = .027). CONCLUSIONS: Our study demonstrated a significant rate of passive transfer of SARS-CoV-2 spike protein IgG antibodies through platelet transfusions. Considering the volume of daily platelet transfusions, this is something all clinicians should be aware of.

The Impact of Physicians' COVID-19 Pandemic Occupational Experiences on Mental Health.

OBJECTIVE: To examine the association between a number of negative COVID-19 occupational experiences and probable anxiety, depression, and PTSD among physicians. METHODS: Cross-sectional examination of longitudinal registry data consisting of physician personal and occupational well-being. Multivariable logistic regressions were performed to determine the association between negative COVID-19 experiences and outcomes. RESULTS: Of the 620 eligible physicians, approximately half were female (49%), and 71% white with a mean age of 46.51 (SD = 13.28). A one-point increase in negative experience score was associated with a 23% increase in probable anxiety (OR = 1.23, 95% CI: 1.14-1.34), a 23% increase in probable depression (OR = 1.23, 95% CI: 1.13-1.33), and a 41% increase in probable PTSD (OR = 1.41, 95% CI: 1.30-1.52). CONCLUSIONS: Negative pandemic experiences were strongly associated with adverse mental health outcomes while greater resilience was protective.

Evaluating burnout during the COVID-19 pandemic among physicians in a large health system in New York.

PURPOSE: The COVID-19 pandemic has generated significant psychological distress among health care workers worldwide. New York State, particularly New York City and surrounding counties, were especially affected, and experienced over 430,000 COVID-19 cases and 25,000 deaths by mid-August 2020. We hypothesized that physicians and trainees (residents/fellows) who were redeployed outside of their specialty to treat COVID-19 inpatients would have higher burnout. METHODS: We conducted a cross-sectional survey to assess burnout among attending and trainee physicians who provided patient care during the COVID-19 pandemic between March-May 2020 across a diverse health care system in New York. Separate multivariable logistic regressions were performed to determine the association between redeployment and measures of burnout: Emotional Exhaustion (EE) and Depersonalization. Burnout measures were also compared by physician vs trainee status. The differential association between redeployment and outcomes with respect to trainee status was also evaluated. RESULTS: Redeployment was significantly associated with increased odds of EE {OR =1.53, 95% CI: 1.01-2.31} after adjusting for gender and Epidemic-Pandemic Impacts Inventory (EPII) score. Similarly, being a trainee, especially a junior level trainee, was associated with increased odds of EE {OR = 1.59, 95% CI: 1.01-2.51} after adjusting for gender and EPII scores. However, neither redeployment nor trainee status were significantly associated with Depersonalization. Interactions between redeployment and trainee status were not significant for any of the outcomes (p>.05). CONCLUSION: Physicians who were redeployed to treat COVID-19 patients had higher reported measures of EE. Trainees, irrespective of redeployment status, had higher EE as compared with attendings. Additional research is needed to understand the long-term impact of redeployment on burnout among redeployed physicians. Programs to identify and address potential burnout among physicians, particularly trainees, during pandemics may be beneficial.

Phospholipid Screening Postcardiac Arrest Detects Decreased Plasma Lysophosphatidylcholine: Supplementation as a New Therapeutic Approach.

OBJECTIVES: Cardiac arrest and subsequent resuscitation have been shown to deplete plasma phospholipids. This depletion of phospholipids in circulating plasma may contribute to organ damage postresuscitation. Our aim was to identify the diminishment of essential phospholipids in postresuscitation plasma and develop a novel therapeutic approach of supplementing these depleted phospholipids that are required to prevent organ dysfunction postcardiac arrest, which may lead to improved survival. DESIGN: Clinical case control study followed by translational laboratory study. SETTING: Research institution. PATIENTS/SUBJECTS: Adult cardiac arrest patients and male Sprague-Dawley rats. INTERVENTIONS: Resuscitated rats after 10-minute asphyxial cardiac arrest were randomized to be treated with lysophosphatidylcholine specie or vehicle. MEASUREMENTS AND MAIN RESULTS: We first performed a phospholipid survey on human cardiac arrest and control plasma. Using mass spectrometry analysis followed by multivariable regression analyses, we found that plasma lysophosphatidylcholine levels were an independent discriminator of cardiac arrest. We also found that decreased plasma lysophosphatidylcholine was associated with poor patient outcomes. A similar association was observed in our rat model, with significantly greater depletion of plasma lysophosphatidylcholine with increased cardiac arrest time, suggesting an association of lysophosphatidylcholine levels with injury severity. Using a 10-minute cardiac arrest rat model, we tested supplementation of depleted lysophosphatidylcholine species, lysophosphatidylcholine(18:1), and lysophosphatidylcholine(22:6), which resulted in significantly increased survival compared with control. Furthermore, the survived rats treated with these lysophosphatidylcholine species exhibited significantly improved brain function. However, supplementing lysophosphatidylcholine(18:0), which did not decrease in the plasma after 10-minute cardiac arrest, had no beneficial effect. CONCLUSIONS: Our data suggest that decreased plasma lysophosphatidylcholine is a major contributor to mortality and brain damage postcardiac arrest, and its supplementation may be a novel therapeutic approach.

Mental Health Effects of Hurricane Sandy on Older Adults.

OBJECTIVES: To examine whether hurricane exposure, lack of access to medical care (LAMC), and displacement during Hurricane Sandy were associated with PTSD and other mental health (MH) symptoms among older adult New York residents. METHODS: Participants (N = 411) were ≥60 years old at the time of survey data collection (1-4 years post-Sandy). Outcomes included PTSD, depression, and anxiety symptoms and stress. Hurricane exposure, displacement, and LAMC were primary predictors. RESULTS: Older adults with greater hurricane exposure had increased PTSD, anxiety, and stress symptoms. LAMC had a strong association (ORadj = 4.11) with PTSD symptoms but was not associated with other MH symptoms. Displacement was not associated with MH outcomes. DISCUSSION: This is the first study to examine exposure, displacement, and LAMC together and to examine their varying impacts on different MH outcomes among older adults post-hurricane. Findings support the importance of disaster preparedness interventions tailored to the MH needs of community-dwelling older adults.

Intubated COVID-19 predictive (ICOP) score for early mortality after intubation in patients with COVID-19.

Patients with coronavirus disease 2019 (COVID-19) can have increased risk of mortality shortly after intubation. The aim of this study is to develop a model using predictors of early mortality after intubation from COVID-19. A retrospective study of 1945 intubated patients with COVID-19 admitted to 12 Northwell hospitals in the greater New York City area was performed. Logistic regression model using backward selection was applied. This study evaluated predictors of 14-day mortality after intubation for COVID-19 patients. The predictors of mortality within 14 days after intubation included older age, history of chronic kidney disease, lower mean arterial pressure or increased dose of required vasopressors, higher urea nitrogen level, higher ferritin, higher oxygen index, and abnormal pH levels. We developed and externally validated an intubated COVID-19 predictive score (ICOP). The area under the receiver operating characteristic curve was 0.75 (95% CI 0.73-0.78) in the derivation cohort and 0.71 (95% CI 0.67-0.75) in the validation cohort; both were significantly greater than corresponding values for sequential organ failure assessment (SOFA) or CURB-65 scores. The externally validated predictive score may help clinicians estimate early mortality risk after intubation and provide guidance for deciding the most effective patient therapies.

Patterns of negative seroconversion in ongoing surveys of SARS-CoV-2 antibodies among workers in New York's largest healthcare system.

OBJECTIVES: Given the importance of continued COVID-19 surveillance, our objective was to present findings from a short follow-up survey of workforce SARS-CoV-2 antibody testing in previously seropositive participants and describe associations between work locations and negative seroconversion. METHODS: We conducted a follow-up cross-sectional survey on previously seropositive healthcare workers, using questionnaires and serology testing. Eligible employees previously consented to be contacted were invited by email to participate in a survey and laboratory blood draws. SAS V.9.4 was used to describe employee characteristics and seroconversion status. Binomial regression models were used to calculate unadjusted and adjusted prevalence ratios (PRs) of seronegativity. The multivariable analyses included age, gender, race/ethnicity, region of residence, work location, prior diagnosis/PCR results and days between antibody tests. Unadjusted and adjusted PRs 95% CIs and p values were reported. RESULTS: Of the 3990 employees emailed in the follow-up, 1631 completed an exposure survey and generated a blood-draw requisition form. Average time between serology testing was 4 months. Of the 955 employees with complete serology results, 79.1% were female, 53.4% were white and 46.4% resided in Long Island; 176 participants seroconverted to negative. In multivariable regression analyses adjusted for gender, race/ethnicity and region of residence, younger employees (<20-30 years), intensive care unit workers and those with no/negative prior PCR results were more likely to have negative seroconversion. CONCLUSIONS AND RELEVANCE: Patterns of negative seroconversion showed significant differences by sociodemographic and workplace characteristics. These results contribute information to workplace serosurveillance.

A comparison of COVID-19 inpatients by HIV status.

COVID-19 in-hospital morbidity and mortality in people living with HIV (PLWH) were compared to HIV-negative COVID-19 patients within a New York City metropolitan health system, the hardest hit region in the United States early in the pandemic. A total of 10,202 inpatients were diagnosed with COVID-19, of which 99 were PLWH. PLWH were younger (58.3 years (SD = 12.42) versus 64.32 years (SD = 16.77), p < 0.001) and had a higher prevalence of men (73.7% versus 57.9%, p = 0.002) and Blacks (43.4% versus 21.7%, p < 0.001) than the HIV-negative population. PLWH had a higher prevalence of malignancies (18% versus 7%, p = < 0.001), chronic liver disease (12% versus 3%, p < 0.001), and end-stage renal disease (11% versus 4%, p = 0.007). Use of a ventilator, admission to the ICU, and in-hospital mortality were not different. Of the 99 PLWH, 12 were virally unsuppressed and 9 had CD4% < 14. Two of the 12 virally unsuppressed patients and 4/9 patients with CD4% < 14 died. Ninety-one of the 99 PLWH were on treatment for HIV, and 5 of the 8 not on treatment died. Among PLWH with prior values, absolute CD4 count decreased an average of 192 cells/mm3 at the time of COVID-19 diagnosis (p < 0.001). Hospitalized patients with HIV and COVID-19 coinfection did not have worse outcomes than the general population. Among PLWH, those with CD4%<14 or not on treatment for HIV had higher mortality rates. Those PLWH who received IL-6 inhibitors had lower mortality rates. PLWH given antifungal medications, hydroxychloroquine, antibiotics (including azithromycin), steroids, and vasopressors had higher mortality rates.

Incidence and mortality trends of metastatic prostate cancer: Surveillance, Epidemiology, and End Results database analysis.

INTRODUCTION: In the past decade, prostate cancer screening decreased, raising the concern of delays in diagnosis and leading to an increase in new cases of metastatic prostate cancer. This study evaluated whether these changes may have impacted trends in metastatic prostate cancer incidence and survival. METHODS: Metastatic prostate cancer diagnoses from 2008-2016 were identified from the Surveillance, Epidemiology, and End Results (SEER) 18 registries. Age-adjusted incidence rates per 100 000 were calculated by time periods and demographic variables. Two-year all-cause and prostate cancer-specific mortality were calculated for patients diagnosed from 2008-2014, and multivariable Cox proportional hazards models were used to evaluate the impact of demographic and clinical variables. RESULTS: Incidence rates of metastatic prostate cancer increased by 18% from 2008-2009 to 2014-2016 (incidence rate ratio [IRR]=1.18, 95% confidence interval [CI] 1.14-1.21). This trend was observed across multiple subgroups but was greatest in non-Hispanic Whites and patients living in counties 0-10% below poverty level. There was an overall decreased risk of all-cause and prostate cancer-specific mortality, but unmarried men and men living in counties >20% below poverty level showed statistically significant increased risk of prostate cancer-specific mortality. CONCLUSIONS: Non-Hispanic Whites and the wealthiest subgroups had the largest increase in incidence of metastatic prostate cancer since 2008. Despite trends of decreased risk of prostate cancer-specific mortality, we found certain populations experienced increases in mortality risk. Studies exploring the role of socioeconomic factors on screening and access to newer treatments are needed.

Cooling Blankets in Hospitalized Patients: Time to Reevaluate.

BACKGROUND: The therapeutic benefits and rationale for treating fevers with external cooling methods remain unclear. We aimed to describe the clinical settings in which cooling blankets (CBs) are used. DESIGN: We conducted a retrospective chart review of CB use in adult patients admitted to our tertiary care center over a one-year period. We measured how they are used and correlations between clinical variables and their duration of use. RESULTS: 561 patients were included in our study. The mean highest temperature during hospitalization was 39.35 °C (SD, 0.67). Shivering occurred in 176 patients (31.4%) while on a CB although 303 patients (54%) had no data regarding shivering. Discontinuation of CBs was recorded in only 177 (30.5%) cases. Among these, the median duration of use was 33.37 h (IQR: 18.13-80.38) while the median duration of fever was 22.13 h (IQR 6.67-51.98). Duration of CB use was highly correlated with fever duration (Spearman's rho, 0.771, p < .001), moderately with length of stay (LOS) (rho, 0.425, p < .001), LOS after CB initiation (rho, 0.475, p < .001) and antipyretic use (rho, 0.506, p < .001). No other statistically significant correlations were observed. CONCLUSION: Documentation of CB use including temperature set points, time of discontinuation and duration in EMRs was poor. We could not establish benefits of CB use in this study but observed that almost a third of patients developed adverse effects in the form of shivering. Thus, adverse effects of CB use may outweigh potential benefits. Their use should be reevaluated and institutional protocols developed for their use.

Predictors of emergency department opioid administration and prescribing: A machine learning approach.

INTRODUCTION: The opioid epidemic has altered normative clinical perceptions on addressing both acute and chronic pain, particularly within the Emergency Department (ED) setting, where providers are now confronted with balancing pain management and potential abuse. This study aims to examine patient sociodemographic and ED clinical characteristics to comprehensively determine predictors of opioid administration during an ED visit (ED-RX) and prescribing upon discharge (DC-RX). METHODS: ED visit data of patients ≥18 years old from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2014 to 2017 were used. Opioid prescriptions were determined utilizing Lexicon narcotic drug classifications. Visit characteristics studied included sociodemographic variables, and ED clinical variables, such as chief complaint, and discharge diagnosis. Machine learning methods were used to determine predictors of ED-RX and DC-RX and weighted logistic regressions were performed using selected predictors. RESULTS: Of the 44,227 ED visits identified, patients tended to be female (57.4%), and White (74.2%) with an average age of 46.4 years (SE = 0.3). Weighted proportions of ED-RX and DC-RX were 23.2% and 18.9%, respectively. The strongest predictors of ED-RX were CT scan ordered (OR = 2.18, 95% CI = 1.84-2.58), abdominal pain (OR = 1.93, 95% CI:1.59-2.34) and back pain (OR = 1.81, 95% CI:1.45-2.27). Tooth pain (OR = 6.94, 95% CI = 4.40-10.94) and fracture injury diagnoses (OR = 3.76, 95% CI = 2.72-5.19) were the strongest predictors of DC-RX. CONCLUSIONS: These findings demonstrate the utility of machine learning for understanding clinical predictors of opioid administration and prescribing in the ED, and its potential in informing standardized prescribing recommendations and guidelines.

Longitudinal multi-gene panel assessment of circulating tumor DNA revealed tumor burden and molecular characteristics along treatment course of non-small cell lung cancer.

BACKGROUND: Most studies associating circulating tumor DNA (ctDNA) with outcome in lung cancer treatment were either cross-sectional or, if longitudinal, only analyzed a limited number of genes. This study evaluated the potential of utilizing ctDNA profiled by a panel of common cancer genes to monitor tumor burden and to reveal molecular characteristics of tumor along treatment course. METHODS: Twenty Chinese non-small cell lung cancer (NSCLC) patients with serial plasma samples collected (I) before starting on either first- or second-line treatment, (II) at stable disease on treatment, and (III) upon disease progression, were analyzed for mutations in ctDNA using the PGDx 64-gene panel. Paired statistics compared mutation profiles between any two of the three time points. RESULTS: Proportions with detectable ctDNA decreased from 65% at baseline to 35% at stable disease and rose to 80% at progression (P=0.012, between stable disease and progression); median ctDNA levels (mutated fragments per mL) were 7.8, 0, and 24.7 at the three time points, respectively (P=0.013 between baseline and progression; P=0.007 between stable disease and progression). Although plasma epidermal growth factor receptor (EGFR) mutations were commonly detected, 15% of patients had mutations other than EGFR detected during progression, such as various types of TP53 mutations. CONCLUSIONS: ctDNA profiling in serial blood samples reflected tumor burden over time, and a multi-gene panel was more sensitive in indicating lung cancer progression on treatment than a single gene approach. The detection of additional oncogenic mutations or their disappearance suggested evolution of tumor heterogeneity along treatment course.