Enzalutamide versus abiraterone acetate in the development of new-onset or worsening type 2 diabetes mellitus in patients with metastatic castration-resistant prostate cancer: EVADE study.

PURPOSE: To determine new-onset or worsening T2DM risk in patients with metastatic castration-resistant prostate cancer (mCRPC) receiving abiraterone acetate (AA) vs. enzalutamide (ENZA) in England. METHODS: Records of patients on AA and/or ENZA (2015-2021) were analysed retrospectively from UK- or England-wide databases and data sets. The primary endpoint was new-onset or worsening T2DM, analysed using a Cox model. RESULTS: Of 1382 patients, 84 (6.1%) met the primary endpoint; 42 of 826 patients (5.1%) received ENZA and 42 of 556 patients (7.6%) received AA. Among patients without baseline T2DM (n = 1049), 50 developed new-onset T2DM: 24 (3.9%) on ENZA and 26 (5.9%) on AA. Among patients with baseline T2DM (n = 333), 34 (10.2%) had worsening T2DM: 18 (8.3%) on ENZA and 16 (13.8%) on AA. Patients on ENZA had longer median follow-up (445 vs. 408 days) and treatment duration (164 vs. 139 days) than those on AA, who were also more likely to have new-onset or worsening T2DM than those on ENZA (HR: 1.8; 95% CI: 1.4-2.7; P = 0.0101). The number needed to harm for an additional patient to experience new-onset or worsening T2DM when receiving AA instead of ENZA was 40 overall, 50 in patients without baseline T2DM, and 18 in patients with baseline T2DM. CONCLUSION: Patients with mCRPC receiving AA were more likely to experience new-onset or worsening T2DM than those on ENZA, despite having a shorter treatment duration. Further research is required to substantiate these findings in earlier disease settings with longer treatment duration.

Treatment patterns, healthcare resource utilization and costs of HER2-negative gastric/gastroesophageal junction cancer.

Aim: To describe treatment patterns, healthcare resource utilization and costs in HER2-negative gastric/gastroesophageal (G/GEJ) cancer in the USA. Methods: Retrospective IQVIA Adjudicated Closed Claims database analysis; patients with HER2-negative G/GEJ cancer initiating systemic therapy between October 2016 and December 2019 were identified. Results: Among 1317 patients, platinum plus taxane regimens (54%) were common in neoadjuvant/adjuvant settings. Platinum-taxane (41%) and platinum-fluoropyrimidine (36%) regimens were common first-line therapies in the metastatic setting. Treatment regimens were heterogeneous in later lines. Hospitalization rates ranged from 39% (first-, second-line metastatic settings) to 61% (neoadjuvant/adjuvant setting). High healthcare resource utilization was driven by high outpatient costs. Mean per-patient per-month outpatient costs combining physician office and hospital visits ranged from US$10,944 to $12,582 (representing 52-70% of total costs). Conclusion: For G/GEJ cancer, systemic regimens varied across lines of therapy with variation increasing with subsequent therapy lines; high healthcare costs persist for systemic treatment, particularly outpatient services.

Presentation and outcomes of end stage liver disease patients presenting with septic shock to the emergency department.

BACKGROUND: Patients with end stage liver disease (ESLD) are particularly vulnerable to sepsis. ESLD patients are often excluded from controlled sepsis trials and more data are needed to guide the management of this population. OBJECTIVE: To describe the clinical factors and outcomes of patients with ESLD presenting to the emergency department (ED) with septic shock. METHODS: We performed a retrospective review of patients registered in our dedicated ED adult septic shock pathway. All patients registered between January 2014 and May 2016 were included. Clinical and treatment variables for ESLD patients were compared with non-ESLD patients. A second analysis assessed ESLD survivors compared to non-survivors. RESULTS: 2,584 septic shock patients were enrolled. ESLD was present in 6.2% (n = 161) of patients. Patients with ESLD had higher mortality compared to patients without ESLD 36.6% vs 21.2% (p < 0.001). ESLD patients were more likely to be younger, female, obese, and have other comorbidities. ESLD patients exhibited lower temperature, higher lactate, and higher incidence of acute kidney injury. There was no difference in antibiotics or fluid resuscitation between groups. ESLD patients received more ED vasopressor support. Among ESLD septic shock patients, maximum lactate and presence of pneumonia were independently associated with death. CONCLUSIONS: Patients with ESLD comprise a small but important subgroup of patients with ED septic shock that experience high mortality compared to patients without ESLD. Maximum ED lactate and pneumonia as the source of sepsis are independently associated with adverse outcome and may be used for early recognition of high-risk ESLD sepsis patients.

Impact of shift duration on alertness among air-medical emergency care clinician shift workers.

BACKGROUND: Greater than half of Emergency Medical Services (EMS) shift workers report fatigue at work and most work long duration shifts. We sought to compare the alertness level of EMS shift workers by shift duration. METHODS: We used a multi-site, 14-day prospective observational cohort study design of EMS clinician shift workers at four air-medical EMS organizations. The primary outcome was behavioral alertness as measured by psychomotor vigilance tests (PVT) at the start and end of shifts. We stratified shifts by duration (< 24 h and 24 h), night versus day, and examined the impact of intra-shift napping on PVT performance. RESULTS: One hundred and twelve individuals participated. The distribution of shifts <24 h and 24 h with complete data were 54% and 46%, respectively. We detected no differences in PVT performance measures stratified by shift duration (P > 0.05). Performance for selected PVT measures (lapses and false starts) was worse on night shifts compared to day shifts (P < 0.05). Performance also worsened with decreasing time between waking from a nap and the end of shift PVT assessment. CONCLUSIONS: Deficits in performance in the air-medical setting may be greatest during night shifts and proximal to waking from an intra-shift nap. Future research should examine alertness and performance throughout air-medical shifts, as well as investigate the timing and duration of intra-shift naps on outcomes.

Utility of sun-reactive skin typing and melanin index for discerning vitamin D deficiency.

BackgroundSkin color, a vitamin D status determinant, can be assessed subjectively by Fitzpatrick sun-reactive skin typing (FST) and objectively by melanin index (MI). FST was validated against MI for discerning vitamin D deficiency (serum 25-hydroxyvitamin D (25(OH)D) <20 ng/ml) in children.MethodsWe measured FST, MI, and serum 25(OH)D in healthy, 8- to 18-year-old children from one of two vitamin D trials. MI from forehead, hand, and upper arm split at the median of the more racially balanced study cohort and FST (I-III vs. IV-V) were used for discriminating vitamin D deficiency.ResultsA total of 296 participants (mean age, 12.3±2.3 years; black, 208; FST IV-V, 209; 25(OH)D <20 ng/ml, 159) were studied. MI and FST had a strong positive association. Serum 25(OH)D was negatively associated with MI and FST. Sensitivity, specificity, and predictive values were similar for discriminating vitamin D deficiency between higher vs. lower MI and between FST I-III vs. IV-V. ROC area under the curves for FST (0.59) and MI (forehead (0.63); hand (0.62); and arm (0.64)) were similar.ConclusionsFST is comparable to MI for discerning vitamin D deficiency and can be deemed as an inexpensive, useful surrogate measure of skin color in the context of vitamin D research.

Trends in parastomal hernia repair in the United States: a 14-y review.

BACKGROUND: Parastomal hernia is the most common complication after stoma creation. Parastomal hernias can create significant morbidity, including patient discomfort, small bowel obstruction, and need for emergency surgery. We examined national trends in parastomal hernia repair (PHR) including annual frequency of procedure, patient characteristics, and same-admission complications. MATERIALS AND METHODS: The 1998-2011 Nationwide Inpatient Sample was used to identify patients who underwent a PHR (International Classification of Disease, Ninth Edition, Procedure Code [ICD-9 PR] 46.42). PHRs were classified as PHR with concurrent resiting (ICD-9 PR 46.43), PHR with concurrent ostomy reversal (ICD-9 PR 46.52 or 46.51), or primary PHR. Patient characteristics were collected. Complications, length of stay, cost and inpatient mortality were identified. RESULTS: The estimated number of annual PHRs increased from 4150 to 7623 (P ≤ 0.01) for a total of 73,393 repairs. Thirty percent underwent a concurrent stoma reversal and 10% underwent a resiting. There was an upward trend in number of patients with ≥3 Elixhauser comorbidities (17%-44%, P < 0.01). Length of stay remained steady, with a median of 6.3 d and in-hospital annual mortality ranged from 1.8% to 3.9%. Mortality and emergency admission status were highest for patients who underwent primary PHR. CONCLUSIONS: The incidence of PHR nationwide is increasing and more than half of patients undergo primary repair. Although the surgical focus has moved toward prevention, parastomal hernia is a persistent complication of stoma creation. Further exploration is warranted to determine contributing factors to the observed increase in PHR and changes in surgical technique.

Emergency general surgery transfers in the United States: a 10-year analysis.

BACKGROUND: Emergency general surgery (EGS) admissions account for more than three million hospitalizations in the US annually; and interhospital transfers (IHTs) are costly. We aimed to better understand the population of transferred EGS patients and their subsequent care in a nationally representative sample. METHODS: Using the 2002-2011 Nationwide Inpatient Sample, we identified patients aged ≥18 years with an EGS noncardiovascular principal diagnosis who were transferred from another hospital with urgent or emergent admission status. Patient demographics, hospitalization characteristics, rates of operation, and mortality were identified. Procedure codes were classified into surgery and procedures based on the HCUP Surgery Flag. RESULTS: We identified an estimated 525,913 EGS admissions transferred from another acute care hospital. The mean age was 60 years, 51% were female, and >50% were Medicare patients. The rate of EGS IHTs increased while mortality decreased. Surgery was required for only 33% of transferred patients. The most common surgeries were laparoscopic cholecystectomy, lysis of adhesions, and wound debridement. The median length of stay was 4.4 days, 92% of patients were cared for in urban hospitals, and >50% in teaching hospitals. CONCLUSIONS: The percent of patients with an EGS diagnosis requiring IHT is increasing, which may reflect a trend toward regionalization of EGS. Transfers require significant resources and may delay care. More than half of the EGS patients did not require surgical intervention. Future studies to identify populations who benefit from IHT and ideal timing of transfer can establish opportunities for optimizing resource utilization and patient outcomes.

The First-Time Seizure Emergency Department Electroencephalogram Study.

STUDY OBJECTIVE: Seizures account for 1.2% of all emergency department (ED) visits, with 24% of those representing first-time seizures. Our primary goal is to determine whether obtaining an electroencephalogram (EEG) in the ED after a first-time seizure can identify individuals appropriate for initiation of anticonvulsant therapy on ED discharge. Our secondary goals are to determine the association of historical and clinical seizure features with epileptic EEGs and to determine the interobserver agreement for the EEG interpretation. METHODS: We conducted a prospective study including patients older than 17 years with either a first-time seizure or previous seizures without a previous EEG, all of whom were candidates for discharge home from the ED without antiepileptic drug treatment. We based seizure diagnosis on provider impression. We excluded patients with laboratory studies or neuroimaging deemed to be the seizure cause. EEG technicians performed a 30-minute EEG in the ED, which was immediately remotely interpreted by an epileptologist, who made a recommendation on antiepileptic drug initiation. We categorized EEGs as normal, abnormal but not epileptic, or epileptic. In accordance with duplicate EEG interpretation by a second, blinded epileptologist, we calculated interrater agreement for EEG interpretation and antiepileptic drug initiation. As a secondary analysis, according to questionnaires completed by patients and seizure observers, we explored the association of aura, focal symptoms, provocation, or historical risk factors with epilepsy. RESULTS: We enrolled 73 patients, 71 of whom had an EEG performed. All EEGs were performed within 11 hours of seizure, with an average of 3.85 hours. Twenty-four percent of patients (95% confidence interval 15% to 36%) received a diagnosis of epilepsy, and all began receiving antiepileptic drug therapy from the ED. Our final study sample size afforded only an exploratory analysis about an association between aura, focal onset, provocation, or historical risk factors with an epilepsy diagnosis. Weighted κ agreement for EEG interpretation was 0.69 (95% confidence interval 0.55 to 0.82). Of the 34 patients who followed up with an epileptologist, 9 had received a diagnosis of epilepsy in the ED, and none had antiepileptic drug medication stopped at initial follow-up. CONCLUSION: ED EEG performance in adults with first-time seizures results in a substantial yield of an epilepsy diagnosis and immediate initiation of antiepileptic drug treatment. A larger study is required to determine whether historical and clinical seizure features are associated with an ED epilepsy diagnosis.

Six-Minute Walk Test as a Measure of Walking Capacity in Ambulatory Individuals With Amyotrophic Lateral Sclerosis.

OBJECTIVE: To determine the validity of the 6-minute walk test (6MWT) as an outcome measure to evaluate walking capacity in ambulatory patients with amyotrophic lateral sclerosis (ALS). DESIGN: Observational study. SETTING: Multidisciplinary ALS clinic at an academic medical center. PARTICIPANTS: Patients with ALS (N=186) who ambulate without (stage I) or with (stage II) an assistive device. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Walking distance obtained from the 6MWT. RESULTS: Participants performed the 6MWT, 25-foot walk test (25FWT), Timed Up and Go (TUG) test, lower extremity maximum voluntary isometric contraction (MVIC), ALS Functional Rating Scale-Revised (ALSFRS-R), and forced vital capacity (FVC). Walking capacity was reduced to 66% predicted of healthy subjects (75.2%±22% in stage I; 42.6%±22% in stage II). The 6MWT correlated with all other outcome measures in ambulatory patients with ALS (25FWT: r=-.74, P≤.0001; TUG test: r=-.80, P≤.0001; MVIC: r=.64, P≤.0001; percent predicted FVC: r=.25, P≤.0007; ALSFRS-R: r=.52, P≤.0001; ALSFRS-R gross motor subscore: r=.71, P≤.0001). When ambulatory patients with ALS were stratified by stage of ambulation, the 6MWT was associated with all other outcome measures in stage I (25FWT: r=-.56, P≤.0001; TUG test: r=-.66, P≤.0001; MVIC: r=.51, P≤.0001; percent predicted FVC: r=.40, P≤.02; ALSFRS-R: r=.52, P≤.0001; ALSFRS-R gross motor subscore: r=.61, P≤.0001). In stage II, the 6MWT correlated with the 25FWT (r=-.83, P≤.0001), TUG test (r=-.77, P≤.0001), MVIC (r=.47, P≤.0001), and ALSFRS gross motor subscore (r=.61, P≤.0001), but not with percent predicted FVC (r=.09, P≤.513) or ALSFRS-R (r=.21, P≤.141). CONCLUSIONS: The 6MWT is a valid measure of walking capacity of ambulatory patients with ALS that is associated with measures of lower extremity muscle strength and function in both stages of ambulation. The discordance between the 6MWT with the ALSFRS-R and percent predicted FVC in stage II ambulatory patients with ALS indicates that the 6MWT is an independent measure of ambulatory function in both stages of ambulation. The 6MWT may provide a quantitative, simple, and inexpensive outcome measure of walking capacity for early stage clinical trials in ambulatory patients with ALS.

Morbidity and Mortality in Elective Total Hip Arthroplasty Following Surgical Care Improvement Project Guidelines.

BACKGROUND: Following evidence questioning the safety and efficacy of perioperative beta-blocker therapy in noncardiac surgery, the Surgical Care Improvement Project (SCIP) guidelines were retired in 2015. However, perioperative myocardial infarctions and cardiac complications remain leading causes of mortality following noncardiac surgery. The impact of the SCIP guidelines on reducing cardiac complications in patients undergoing elective total hip arthroplasty (THA) has not been evaluated. METHODS: The Nationwide Inpatient Sample was queried for 345,875 elective THA performed from 2003 to 2011. Patient demographics and morbidity as well as the incidence of nonfatal and fatal cardiac complications and overall mortality associated with cardiac complications were determined before and following SCIP implementation. RESULTS: Following the institution of the SCIP guidelines, the overall mortality following cardiac complications decreased by 41%. Although the incidence of nonfatal cardiac events after THA did increase 5% (primarily secondary to an increased incidence of nonfatal hypotension), the incidence of postoperative inpatient mortality, stroke, fatal hypotension, fatal myocardial infarction, and nonfatal and fatal cardiac arrest significantly decreased. CONCLUSION: Following the implementation of SCIP guidelines, there was a 41% reduction in mortality and a significant decrease in fatal cardiac complications, postoperative hypotension, myocardial infarction, and cardiac arrest. Despite SCIP guidelines being retired in 2015, evidence supports continuation of perioperative beta-blockade in primary elective total adult hip and knee arthroplasty.

Morbidity and Mortality in Elective Total Knee Arthroplasty Following Surgical Care Improvement Project Guidelines.

BACKGROUND: Perioperative myocardial infarctions and cardiac complications are leading causes of mortality after noncardiac surgery. In an effort to improve patient safety, the Surgical Care Improvement Project (SCIP) implemented guidelines concerning administration of ß-blockers therapy aimed to reduce cardiac complications. METHODS: The Nationwide Inpatient Sample was queried for 759,819 elective total knee arthroplasties performed from 2003 to 2011. Incidence of cardiac complications, mortality, and risk factors for cardiac complications was determined before and after SCIP implementation. RESULTS: The incidence of cardiac events after total knee arthroplasty remained stable at 9%. The incidence and mortality of postoperative stroke, myocardial infarction, and cardiac arrest significantly decreased. Mortality after cardiac complications decreased by 50%. CONCLUSION: After the implementation of SCIP guidelines, there was a greater than 50% reduction in mortality and a significant decrease in fatal postoperative stroke, heart failure, and cardiac arrest.

Incorporating a Pharmacist Into the Discharge Process: A Unit-Based Transitions of Care Pilot.

Objective: To evaluate the impact of a multifaceted, pharmacy-driven, unit-based transitions of care (TOC) program on all-cause 30-day readmission rates and to assess readmission rates in predefined subgroup patient populations. Methods: This prospective study included adult patients who were discharged from the pilot unit from January 5 to January 30, 2015. Patients who expired during hospitalization, left the hospital against medical advice, or transferred to another unit or nonaffiliated hospital were excluded. Possible pharmacist interventions included daily medication profile review, delivery of discharge medications to the bedside, counseling, and communication of a discharge medication list to follow-up providers. Patients had a 30-day follow-up period from the date of discharge to assess for readmission. Results: A total of 131 patients were screened and 94 patients were included. The primary outcome evaluating 30-day readmission rates occurred in 12.8% of patients in the pilot group versus 18.8% of patients in the historical control group (p = .26). None of the patients who received all possible pharmacist interventions were readmitted. Secondary outcomes assessing readmission rates in predefined subgroup populations as well as length of stay were comparable between the 2 groups. All identified medication discrepancies were resolved prior to discharge. Conclusion: Readmission rates during the pilot were numerically lower but not statistically significant when compared with historical data. Enhancement of the pharmacy-driven TOC services through allocation of additional resources is in progress. Further investigation is warranted to determine the impact of a TOC pharmacist after the service is sustained.

Increased Anesthesia Usage in a Large-Volume Endoscopy Unit: Patient Acuity Is Not the Main Predictor.

OBJECTIVES: The use of monitored anesthesia care (MAC) for colonoscopy sedation continues to increase. This study examined trends during a 9-year period in the use of MAC and explored which patient variables may have influenced these trends. METHODS: This was a retrospective review of all colonoscopies performed in our hospital-based endoscopy unit from 2003 through 2012. We determined whether MAC was used and if not, which quantitative doses of sedative agents were used. Several patient-related variables were evaluated for correlation. Data were analyzed (t test, χ(2), logistic regression) using SAS statistical software. RESULTS: Between January 2003 and October 2012, we identified 37,803 performed colonoscopies. The use of MAC increased significantly, from 0.38% in 2003 to 10.0% in 2012 (P < 0.0001). For cases in which conscious sedation was used, the mean doses of sedatives did not change significantly over time. Although there was an association between certain patient variables (female sex; higher American Society of Anesthesiologists class; diagnostic procedures; and pulmonary, psychiatric, renal or cerebrovascular diseases) and the use of MAC, the greatest predictor of MAC use was the year of the procedure. After adjusting for the patient variables that were examined, the odds of using MAC increased by approximately 1.5 times per year from 2003 through 2012. The adjusted odds of using MAC in 2012 were 35.8 times higher than in 2003. CONCLUSIONS: The use of MAC for colonoscopies performed in our endoscopy unit increased significantly from 2003 to 2012. Although increased MAC use was associated with some patient variables, it was most significantly associated with the year of the procedure. This suggests that there were other nonpatient-related factors influencing its use.

Dry Age-Related Macular Degeneration: Distribution of Visual Acuity and Progression Risk in a Large Registry.

INTRODUCTION: Understanding the progression to geographic atrophy (GA) in late dry age-related macular degeneration (dAMD) can support development opportunities for dAMD treatments. We characterized dAMD by distribution of visual acuity (VA) categories and evaluated VA progression risk by disease stage. METHODS: This retrospective observational study used data from the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) to identify patients diagnosed with dAMD in ≥ 1 eye from January 2016 through December 2019 (index date) with ≥ 1 visit and ≥ 1 VA measurement recorded post-index date. Patients were followed until the date of last visit, last contribution for diagnosing provider, or diagnosis of neovascular AMD post-index. Models were utilized to describe the distribution of VA categories and progression to worsening VA. RESULTS: Data from 593,277 patients were analyzed. At baseline, 64.4% had mild disease, 29.4% intermediate, and 2.9%/3.3% had GA with/without subfoveal involvement. Most patients with mild (88.4%) and intermediate (79.7%) disease and GA without subfoveal involvement (57.1%) had baseline VA ≥ 20/63 in the study eye; 72.0% of patients with GA with subfoveal involvement had VA < 20/63. Modeled results showed lower VA with more progressive stage at baseline. Annual probability of stable dAMD based on baseline stage ranged from 82.1% (GA without) to 92.3% (GA with subfoveal involvement). Annual progression probability to GA without/with subfoveal involvement was 0.4% for mild and 5.5% for intermediate disease and from dry to neovascular AMD, 0.5% for mild and 8.0% for intermediate disease. CONCLUSIONS: Results from this analysis of a large database of electronic health records complement those from randomized trials and show that patients with more advanced dAMD have lower VA at baseline and that VA progression is generally faster with each progressive stage. Together these findings highlight the disease burden and trajectory of dAMD as well as opportunities for addressing unmet needs.

Dry age-related macular degeneration (dAMD) is a disease that progressively worsens over time. As the disease progresses, patients start to lose their vision, leading to a substantial burden on their quality of life and finances due to the need for increased healthcare services. As of 2022, there are no medications available to reverse or stop worsening of dAMD. This study used real-world data from a large registry of electronic health records to increase the understanding of how patients progress through the stages of dAMD. By reviewing patient records, we were able to identify approximately 600,000 patients with confirmed dAMD. These patients were then followed over time, and we were able to confirm that patients with a lower ability to see at the beginning of our review period had more advanced dAMD. We also found that as patients' disease worsened, their vision also decreased. These findings highlight the need for new medication options to reverse or delay the worsening of dAMD and improve the quality of life for patients.

Compliance to Advisory Committee on Immunization Practices recommendations for pneumococcal vaccination.

We evaluated compliance to the ACIP pneumococcal vaccination recommendations issued in 2014 for adults aged ≥ 65 years and in 2012 for adults with high-risk (HR) conditions. The MarketScan® Commercial and Medicare Supplemental databases (January 2007-June 2019) were used to identify the cohorts of interest. Analyses for adults aged ≥ 65 years were adjusted to account for missing vaccination history. Two HR cohorts were identified. The HR1 cohort included patients with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leak, or cochlear implant. The HR2 cohort included patients with chronic heart, lung, or liver disease; diabetes mellitus; alcoholism; cirrhosis; or cigarette smoking. Full compliance for those aged ≥ 65 years or in the HR1 cohort was defined as receipt of PCV13 and PPSV23, and partial compliance was defined as receipt of PCV13 or PPSV23. For those in the HR2 cohort, full compliance was defined as receipt of PPSV23. Annual compliance rates were estimated using the Kaplan-Meier method. Among those aged ≥ 65 years, partial compliance at 4 years post index was 53% and full compliance was 17% in adjusted analyses. In subjects ≥ 65 years receiving the first vaccination, 42% received the second vaccination by year 4. For the HR1 cohort, partial compliance was 19% and full compliance was 5% at 6 years post index date. For the HR2 cohort, full compliance was 20% at 6 years, with the highest rate in patients with diabetes (27%) and the lowest rate in patients with alcoholism (8%). Additional efforts are needed to maximize compliance to the ACIP pneumococcal vaccine recommendations among adults ≥ 65 years of age and adults with HR conditions including streamlined recommendations and single-dose vaccines. These efforts may subsequently reduce the incidence and burden of pneumococcal disease.

Incidence and risk factors associated with early death in patients with emergency department septic shock.

BACKGROUND: Limited research has explored early mortality among patients presenting with septic shock. The objective of this study was to determine the incidence and factors associated with early death following emergency department (ED) presentation of septic shock. METHODS: A prospective registry of patients enrolled in an ED septic shock clinical pathway was used to identify patients. Patients were compared across demographic, comorbid, clinical, and treatment variables by death within 72 hours of ED presentation. RESULTS: Among the sample of 2,414 patients, overall hospital mortality was 20.6%. Among patients who died in the hospital, mean and median time from ED presentation to death were 4.96 days and 2.28 days, respectively. Death at 24, 48, and 72 hours occurred in 5.5%, 9.5%, and 11.5% of patients, respectively. Multivariate regression analysis demonstrated that the following factors were independently associated with early mortality: age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.03-1.05), malignancy (OR, 1.53; 95% CI, 1.11-2.11), pneumonia (OR, 1.39; 95% CI, 1.02-1.88), urinary tract infection (OR, 0.63; 95% CI, 0.44-0.89), first shock index (OR, 1.85; 95% CI, 1.27-2.70), early vasopressor use (OR, 2.16; 95% CI, 1.60-2.92), initial international normalized ratio (OR, 1.14; 95% CI, 1.07-1.27), initial albumin (OR, 0.55; 95% CI, 0.44-0.69), and first serum lactate (OR, 1.21; 95% CI, 1.16-1.26). CONCLUSIONS: Adult septic shock patients experience a high rate of early mortality within 72 hours of ED arrival. Recognizable clinical factors may aid the identification of patients at risk of early death.

Intracortical lesions by 3T magnetic resonance imaging and correlation with cognitive impairment in multiple sclerosis.

BACKGROUND: Accurate classification of multiple sclerosis (MS) lesions in the brain cortex may be important in understanding their impact on cognitive impairment (CI). Improved accuracy in identification/classification of cortical lesions was demonstrated in a study combining two magnetic resonance imaging (MRI) sequences: double inversion recovery (DIR) and T1-weighted phase-sensitive inversion recovery (PSIR). OBJECTIVE: To evaluate the role of intracortical lesions (IC) in MS-related CI and compare it with the role of mixed (MX), juxtacortical (JX), the sum of IC + MX and with total lesions as detected on DIR/PSIR images. Correlations between CI and brain atrophy, disease severity and disease duration were also sought. METHODS: A total of 39 patients underwent extensive neuropsychological testing and were classified into normal and impaired groups. Images were obtained on a 3T scanner and cortical lesions were assessed blind to the cognitive status of the subjects. RESULTS: Some 238 cortical lesions were identified (130 IC, 108 MX) in 82% of the patients; 39 JX lesions were also identified. Correlations between CI and MX lesions alone (p = 0.010) and with the sum of IC + MX lesions (p = 0.030) were found. A correlation between severity of CI and Expanded Disability Status Scale was also seen (p = 0.009). CONCLUSION: Cortical lesions play an important role in CI. However, our results suggest that lesions that remain contained within the cortical ribbon do not play a more important role than ones extending into the adjacent white matter; furthermore, the size of the cortical lesion, and not the tissue-specific location, may better explain their correlation with CI.

Protective role of hemoglobin and fetal hemoglobin in early kidney disease for children with sickle cell anemia.

Patients with sickle cell anemia are at risk for organ damage including kidney disease. Microalbuminuria may be an early marker of disease progression. This retrospective review analyzed laboratory and clinical findings in children with sickle cell anemia according to the presence or absence of MA during well clinic sickle cell visits. Results were analyzed in sum as well as by therapeutic intervention (not on therapy,hydroxyurea therapy, or chronic transfusion therapy). Thirty two of 144(22%) children had MA, including 20 of 82 (24%) children not on a therapeutic intervention (chronic transfusion or hydroxyurea). In children not on therapy, low hemoglobin, low fetal hemoglobin and high lactate dehydrogenase were associated with MA. Frequency of positive screens for MA for the different treatment groups were: Hydroxyurea 13%; chronic transfusion 26% and children on no treatment 24%. However,the difference between the hydroxyurea group and the chronic transfusion or no treatment groups did not reach statistical significance.Increased hemoglobin and fetal hemoglobin may provide protection against kidney disease in sickle cell anemia and should be evaluated in a randomized, prospective clinical trial.

Implementation of a comprehensive intervention focused on hospitalized patients with HIV by an existing stewardship program: successes and lessons learned.

BACKGROUND: Several national organizations have advocated for inpatient antiretroviral stewardship to prevent the consequences of medication-related errors. This study aimed to evaluate the impact of a stewardship initiative on outcomes in people with HIV (PWH). METHODS: A pharmacist-led audit and review of adult patients admitted with an ICD-10 code for HIV was implemented to an existing antimicrobial stewardship program. A quasi-experimental, retrospective cohort study was conducted comparing PWH admitted during pre- and post-intervention periods. Rates of antiretroviral therapy (ART)-related errors and infectious diseases (ID) consultation with linkage to care were evaluated through selection of a random sample of patients receiving ART in each period. Length of stay (LOS) and mortality were assessed by analyzing all admissions in the post-intervention period. Clinical outcomes including LOS, 30-day all-cause hospital readmission, and in-hospital and 30-day mortality in the post-intervention group were stratified by patients not on ART, on ART at admission, and started on ART as a result of the intervention. RESULTS: A total of 100 patients in the pre-intervention period and 103 patients in the post-intervention period were included to assess ART-related errors and linkage to care. A reduction in errors (70.0 versus 25.7%, p < 0.001) and increased linkage to care (19.0 versus 39.6%, p < 0.01) were demonstrated. Of 389 admissions during the post-intervention period, 30-day mortality rates were similar between PWH on ART at admission and those initiated on ART during admission (5% versus 8%, respectively), but less than those not on ART (21%). A longer LOS was observed in the patients started on ART during admission (5 days if ART started during admission versus 3 days if not started during admission, p < 0.01). CONCLUSIONS: This interdisciplinary intervention was successful in reducing inpatient ART-related errors and increasing ID consultation with linkage to care among PWH.

Palliative Care in Emergency General Surgery Patients: Reduced Inpatient Mortality And Increased Discharge to Hospice.

BACKGROUND: Admissions due to emergency general surgery (EGS) are on the rise, and patients who undergo emergency surgery are at increased risk of mortality. We hypothesized that utilization of palliative care and discharge to hospice in the EGS population have increased over time and that this is associated with a decrease in inpatient mortality. METHODS: Using the 2002-2011 nationwide inpatient sample and American Association for the Surgery of Trauma-defined EGS diagnosis codes, we identified patients ≥18 years old with an EGS admission. Demographics, hospitalization characteristics, mortality, use of palliative care services, and discharge to hospice were queried. All Patient Refined-Diagnosis Related Group risk of mortality was used to categorize those with an extreme likelihood of dying (ELD). Multivariable logistic regression was used to investigate the association between palliative care consult and discharge to hospice. RESULTS: Of the included patients, 0.3% received palliative care and 0.2% were discharged to hospice. Over time, rates of palliative care and hospice discharge increased while inpatient mortality decreased. In the 4% of patients with ELD, 3% received palliative care, 5% were transitioned to hospice care, and 22% suffered inpatient mortality. Controlling for patient characteristics, utilization of palliative care services was associated with increased odds of discharge to hospice compared to inpatient mortality (OR = 1.78 all patients and OR = 2.04 for ELD). CONCLUSIONS: Despite the known increased risks associated with emergency surgical diagnoses, palliative care services remain infrequently utilized in the EGS population. This may be an opportunity for lessening suffering, improving patient-concordant care and outcomes, and reducing nonbeneficial and unwanted care.