A Comprehensive Analysis of the Impact of the COVID-19 Pandemic on Lung Cancer in Delaware.

Background: COVID-19 has greatly impacted the U.S. health system. What is not as well-understood is how this has altered specific aspects of lung cancer care. While cancer incidence and screening have been affected, it is not known whether pre-existing racial and socioeconomic disparities worsened or if treatment standards changed. The purpose of this study is to provide a comprehensive analysis of the impact of COVID-19 on lung cancer in the state of Delaware. Methods: Health care claims were analyzed from the Delaware Healthcare Claims Database for the years 2019-2020. Patients with a new lung cancer diagnosis and those who had undergone lung cancer screening were identified. Demographic and socioeconomic variables including gender, age, race, and insurance were studied. Patients were analyzed for type of treatment by CPT code. The intervention of interest in this study was the institution of restrictions at the end of March 2020. An interrupted time series analysis (ITSA) was utilized to evaluate baseline levels and overall trend changes. Results: The incidence of lung cancer diagnoses and lung cancer screenings decreased in the nine-month time period after the initiation of COVID-19 lockdowns. Demographic and socioeconomic variables including gender, race, income, and education level were not affected; however, statistical differences were seen in the most elderly subgroup. Treatment modalities including number of surgeries, chemotherapy, and radiation therapy did not change significantly. Conclusions: COVID-19 has had a significant impact on lung cancer care within the state of Delaware. Lung cancer incidence, screenings, and elderly patients were affected the most.

Retrospective Review of Transpulmonary Pressure Guided Positive End-Expiratory Pressure Titration for Mechanical Ventilation in Class II and III Obesity.

OBJECTIVES: Acute respiratory distress syndrome is treated by utilizing a lung protective ventilation strategy. Obesity presents with additional physiologic considerations, and optimizing ventilator settings may be limited with traditional means. Transpulmonary pressure (PL) obtained via esophageal manometry may be more beneficial to titrating positive end-expiratory pressure (PEEP) in this population. We sought to determine the feasibility and impact of implementation of a protocol for use of esophageal balloon to set PEEP in obese patients in a community ICU. DESIGN: Retrospective cohort study of obese (body mass index [BMI] ≥ 35 kg/m2) patients undergoing individualized PEEP titration with esophageal manometry. Data were extracted from electronic health record, and Wilcoxon signed rank test was performed to determine whether there were differences in the ventilatory parameters over time. SETTING: Intensive care unit in a community based hospital system in Newark, Delaware. PATIENTS: Twenty-nine mechanically ventilated adult patients with a median BMI of 45.8 kg/m2 with acute respiratory distress syndrome (ARDS). INTERVENTION: Individualized titration of PEEP via esophageal catheter obtained transpulmonary pressures. MEASUREMENTS AND MAIN RESULTS: Outcomes measured include PEEP, oxygenation, and driving pressure (DP) before and after esophageal manometry at 4 and 24 hr. Clinical outcomes including adverse events (pneumothorax and pneumomediastinum), increased vasopressor use, rescue therapies (inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, and new prone position), continuous renal replacement therapy, and tracheostomy were also analyzed. Four hours after PEEP titration, median PEEP increased from 12 to 20 cm H2O (p < 0.0001) with a corresponding decrease in median DP from 15 to 13 cm H2O (p = 0.002). Subsequently, oxygenation improved as median Fio2 decreased from 0.8 to 0.6 (p < 0.0001), and median oxygen saturation/Fio2 (S/F) ratio improved from 120 to 165 (p < 0.0001). One patient developed pneumomediastinum. No pneumothoraces were identified. Improvements in oxygenation continued to be seen at 24 hr, compared with the prior 4 hr mark, Fio2 (0.6-0.45; p < 0.004), and S/F ratio (165-211.11; p < 0.001). Seven patients required an increase in vasopressor support after 4 hours. Norepinephrine and epinephrine were increased by 0.05 (± 0.04) µg/kg/min and 0.02 (± 0.01) µg/kg/min on average, respectively. CONCLUSIONS: PL-guided PEEP titration in obese patients can be used to safely titrate PEEP and decrease DP, resulting in improved oxygenation.

Impact of a Dedicated Teaching Attending Experience on a Required Emergency Medicine Clerkship.

INTRODUCTION: One published strategy for improving educational experiences for medical students in the emergency department (ED) while maintaining patient care has been the implementation of dedicated teaching attending shifts. To leverage the advantages of the ED as an exceptional clinical educational environment and to address the challenges posed by the rapid pace and high volume of the ED, our institution developed a clerkship curriculum that incorporates a dedicated clinical educator role - the teaching attending - to deliver quality bedside teaching experiences for students in a required third-year clerkship. The purpose of this educational innovation was to determine whether a dedicated teaching attending experience on a third-year required emergency medicine (EM) clerkship would improve student-reported clinical teaching evaluations and student-reported satisfaction with the overall quality of the EM clerkship. METHODS: Using a five-point Likert-type scale (1 - poor to 5 - excellent), student-reported evaluation ratings and the numbers of graduating students matching into EM were trended for 10 years retrospectively from the inception of the clerkship for the graduating class of 2009 through and including the graduating class of 2019. We used multinomial logistic regression to evaluate whether the presence of a teaching attending during the EM clerkship improved student-reported evaluation ratings for the EM clerkship. We used sample proportion tests to assess the differences between top-box (4 or 5 rating) proportions between years when the teaching attending experience was present and when it was not. RESULTS: For clinical teaching quality, when the teaching attending is present the estimated odds of receiving a rating of 5 is 77.2 times greater (p <0.001) than when the teaching attending is not present and a rating of 4 is 27.5 times greater (p =0.0017). For overall clerkship quality, when the teaching attending is present, the estimated odds of receiving a rating of 5 is 13 times greater (p <0.001) and a rating of 4 is 5.2 times greater (p=0.0086) than when the teaching attending is not present. CONCLUSION: The use of a dedicated teaching attending shift is a successful educational innovation for improving student self-reported evaluation items in a third-year required EM clerkship.

Performance of estimated glomerular filtration rate prediction equations in preeclamptic patients.

Accurate estimation of the glomerular filtration rate (GFR) in patients with preeclampsia requires the collection of a 24-hour urine and can have important therapeutic and diagnostic implications. This procedure is often difficult or impossible to accomplish in this patient group. In this study, the Cockcroft-Gault, the Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas were evaluated for their accuracy in determining GFR in the setting of preeclampsia. The estimated GFRs calculated from the above formulas were compared with the creatinine clearance values obtained from a 24-hour urine collections in 543 preeclamptic patients recruited from several large hospitals. Additionally, a set of new equations, preeclampsia GFR (PGFR), based on ethnicity, was created. The Cockcroft-Gault, MDRD, and CKD-EPI formulas were inaccurate in predicting GFR and both were significantly less accurate than PGFR. The latter formula provided an estimated GFR that was much closer to the creatinine clearance. Current GFR estimation equations based on serum creatinine values in nonpregnant patients are not reliable measures of renal function in patients with preeclampsia. The use of a new formula (PGFR) is recommended.

Estimation of glomerular filtration rate in preeclamptic patients.

Accurate estimation of the glomerular filtration rate (GFR) in patients with preeclampsia is often difficult or impossible to accomplish. In this study, the Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), and MDRD2 formulas were evaluated for their accuracy in determining GFR in the setting of preeclampsia. The estimated GFR calculated from these formulas was compared with the creatinine clearance values obtained from a 24-hour urine collection in 209 preeclamptic patients recruited from five large hospitals. Additionally, a set of new equations that more accurately estimate GFR in preeclamptic patients based on ethnicity, preeclampsia GFR (PGFR), was created. Both the CG and MDRD formulas were inaccurate in predicting GFR in preeclamptic patients, and both were significantly less accurate than PGFR. In conclusion, current GFR estimation equations based on serum creatinine values in nonpregnant patients are not reliable measures of renal function in patients with preeclampsia. The use of a new (PGFR) formula is recommended.

Effect of dietary fiber intake on blood pressure: a meta-analysis of randomized, controlled clinical trials.

OBJECTIVE: We conducted a meta-analysis of 25 randomized controlled trials published in English-language journals before February 2004, to assess the effect of dietary fiber intake on blood pressure (BP). DESIGN: Using a standardized protocol, information on study design, sample size, participant characteristics, duration of follow-up and change in mean BP, was abstracted. The data from each study were pooled using a random effects model to provide an overall estimate of dietary fiber intake on BP. INTERVENTION: Dietary fiber intake was the only significant intervention difference between the active and control groups. RESULTS: Overall, dietary fiber intake was associated with a significant -1.65 mmHg [95% confidence interval (CI), -2.70 to -0.61] reduction in diastolic BP (DBP) and a non-significant -1.15 mmHg (95% CI, -2.68 to 0.39) reduction in systolic BP (SBP). A significant reduction in both SBP and DBP was observed in trials conducted among patients with hypertension (SBP -5.95 mmHg, 95% CI, -9.50 to -2.40; DBP -4.20 mmHg, 95% CI, -6.55 to -1.85) and in trials with a duration of intervention > or = 8 weeks (SBP -3.12 mmHg, 95% CI, -5.68 to -0.56; DBP -2.57 mmHg, 95% CI, -4.01 to -1.14). CONCLUSIONS: Our results indicate that increased intake of dietary fiber may reduce BP in patients with hypertension and suggests a smaller, non-conclusive, reduction in normotensives. An intervention period of at least 8 weeks may be necessary to achieve the maximum reduction in BP. Our findings warrant conduct of additional clinical trials with a larger sample size and longer period of intervention to examine the effect of dietary fiber intake on BP.