Urban Teaching Hospital Research Articles

ICU Admission Preferences in the Hypothetical Event of Acute Critical Illness: A Survey of Very Old Norwegians and Their Next-of-Kins.

To explore older patients' ICU admission preferences and their next-of-kins' ability to predict these preferences. Self-administered survey. Three outpatient clinics, urban tertiary teaching hospital, Norway. Purposive sample of outpatients 80 years old or older regarded as potential ICU candidates and their next-of-kins. None. We asked about the patients' ICU admission preferences in three hypothetical scenarios of acute critical illness. Next-of-kin respondents were asked to make a proxy statement regarding the older respondents' wishes regarding ICU admission. For each treatment choice, all respondents could provide their level of confidence. Additionally, we sought to identify demographic and healthcare-related characteristics that potentially influenced ICU admission preferences and proxy accuracy. Of 202 outpatients 80 years old or older, equal proportions opted for (39%; CI, 33-45%) and against (40%; CI, 34-46%) ICU admission, and one in five (21%; CI, 17-26%) did not wish to engage decision-making. Male gender, religiosity, and prior ICU experience increased the likelihood of older respondents opting for ICU admission. Although next-of-kins' proxy statements only weakly agreed with the older respondents' true ICU admission preferences (52%; CI, 45-59%), they agreed with the next-of-kins' own ICU admission preferences (79%; CI, 73-84%) to a significantly higher degree. Decisional confidence was high for both the older and the next-of-kin respondents. In this purposive sample of Norwegian potential ICU candidates 80 years old or older, we found substantial variation in the ICU admission preferences of very old patients. The next-of-kins' proxy statements did not align with the ICU admission preferences of the older respondents in half of the pairs, but next-of-kins' and older respondents' confidence levels in rendering these judgments were high.

A Decade Long Analysis of Healthcare Disparities and Uterine Artery Embolization: An Exploration of Social Determinants of Health

To determine the extent that social determinants of health have on uterine artery embolization (UAE) utilization for treatment of symptomatic uterine fibroids. In this IRB-exempt study, data from the 2011-2020 National Inpatient Sample was used to identify patients with ICD-9 and -10 codes of uterine fibroids who underwent UAE. Data collected included: patient's demographics (race/ethnicity, income, insurance status) and procedure location (geographic region, hospital setting). Results are presented in percentage (UAE procedures per variable) and analyzed using Chi-square test. UAE utilization by race/ethnicity demonstrated the following distribution: Non-Hispanic Blacks (45.6%), Non-Hispanic Whites (28.1%), Hispanics (14.2%) and Asians (5.7%). The lowest quartile for income experienced no change in utilization (27.8%), while the highest quartile gradually decreased across the decade (2011:26.7%, 2020:19.0%, p=0.01). The Northeast region of the US (49.0% in 2011) was superseded by the South (34.8% in 2020) as the dominant geographic region for UAE. The main insurance statuses were private (55.5%) and Medicaid (26.2%), with Medicaid rates increasing throughout the decade (2011:18.2%, 2020: 28.6%, p < 0.001). Urban teaching hospitals accounted for the highest rates of total UAE (82.3%), compared to urban non-teaching (16.0%) and rural hospitals (1.2%). Over the past decade, UAE has been performed in a relatively equitable fashion on the basis income, with improved utilization within the Medicaid population and throughout the geographic regions of the US. When accounting for US population representation and unequal disease burden, Non-Hispanic Blacks demonstrated a greater-than-expected utilization of UAE, compared to lower-than-expected rates among Non-Hispanic Whites.

Racial and Socioeconomic Disparities in Traumatic Brain Injury Outcomes: Insights From a Nationwide Analysis

BACKGROUND AND OBJECTIVES: To examine the effects of racial and socioeconomic disparities on clinical outcomes: in-hospital mortality, discharge dispositions, and hospital length of stay (LOS) among patients with traumatic brain injury (TBI) stratified by race and socioeconomic status (SES). METHODS: We conducted a retrospective analysis by analyzing the 1995-2015 Nationwide Inpatient Sample database. Adjusted logistic regressions and multinomial logistic regression models with and without propensity score matching were applied to investigate the effects of disparities on clinical outcomes. RESULTS: African American and Hispanic patients with TBI had a lower risk of in-hospital mortality, longer hospital LOS, and lower likelihood of being discharged to rehabilitation compared with White patients. The TBI patients with poor SES (pSES) had lower in-hospital mortality and were more likely to leave against medical advice compared with non-pSES TBI patients. CONCLUSION: Racial and socioeconomic disparities had significant influences on in-hospital mortality, discharge dispositions, and hospital LOS among the TBI population. Our study observed pSES TBI patients had a lower likelihood of in-hospital mortality than non-pSES patients, which may be partially attributed to the fact that most of the pSES TBI patients were hospitalized in urban teaching hospitals and hospitals with large bed size. In effect, our data suggest that the Social Safety Net of the United States is effective in preventing mortality in patients with TBI.

Picturing Empathy in the Intensive Care Unit: Patient Photographs at an Urban Community Teaching Hospital.

Intensive care unit (ICU) clinicians are at risk for burnout, which can be driven by depersonalization. Photographs of patients in their baseline state of health before ICU admission may enhance the connection between clinicians and patients. The use of patient photographs has not been evaluated in an urban community teaching hospital. To evaluate whether an interprofessional group of clinicians perceive that patient photographs in the ICU help them connect with patients and enhance empathy. A prospective observational quality improvement study was performed in the medical ICU of an urban community teaching hospital. Patients' families could display patients' photographs in the unit. Registered nurses, physicians, respiratory therapists, and patient care associates completed anonymous surveys. Families of 21 patients provided photographs; 82 clinicians (47 physicians, 25 nurses, 5 respiratory therapists, and 5 patient care associates) completed surveys. Most clinicians (83%) agreed that the patient's personality and character were emphasized by photographs, 77% agreed that photographs facilitated communication with the patient and/or family, 89% agreed that patient photographs helped them relate to the patient as an individual, and 76% were not upset by comparing the photograph with the patient. Responses did not significantly differ by clinician type. Survey comments highlighted themes of humanization, fulfillment, and hope. Patient photographs may enhance connections between clinicians and patients in the ICU, potentially reducing depersonalization and burnout.

Association between patient-reported frailty and nonhome discharge among older patients with acute stroke: A prospective study

Objective To investigate the association between prestroke frailty and nonhome discharge, prolonged length of stay as well as functional outcomes. Design Prospective observational study. Setting Single urban teaching hospital in Guangzhou, China. Participants Consecutive sample of 271 older patients admitted with acute stroke. Intervention N/A. Main measures A five-item FRAIL scale (0∼5 points) and the stroke severity at onset were measured. The primary outcome of interest was nonhome discharge, with secondary outcomes including prolonged length of stay and worse short-term prognosis. Multivariable logistic regression adjusting for confounding factors was used to determine the association between patient-reported frailty and nonhome discharge, prolonged length of stay, worse short-term prognosis. Results The population had a median age of 68 [interquartile range (IQR), 64∼74)]years, with 50 individuals (18.5%) identified as frail. After adjusting for age, sex, Barthel index, National Institutes of Health Stroke Scale, and Mini-Mental Status Exam score at admission, patients with self-reported frailty were significantly likely to experience nonhome discharge (Odds Ratio [OR] = 4.788; 95% confidence interval [CI] = 1.272∼18.017; p = .021), prolonged length of stay (OR = 4.76; 95% CI = 1.80∼12.56; p = .002), mRS scores at 30 days (OR = 6.72;95% CI = 1.79∼25.20; p = .005) and three months postdischarge and three-month (OR = 8.94; 95% CI = 2.10∼38.08; p = .003). Conclusions In older adults with stroke, frailty is associated with nonhome discharge, prolonged length of stay, and worse short-term prognosis, regardless of the stroke severity, cognition, and Barthel index score at admission. FRAIL scale can be used as a practical screening tool in acute care setting by multidisciplinary team in supporting discharge process.

Skin injury: Associations with variables related to perfusion and pressure.

Skin injuries are a major healthcare problem that are not well understood or prevented in the critically ill, suggesting that underappreciated variables are contributing. This pilot study tested the hypothesis that perfusion-related factors contribute to skin injuries diagnosed as hospital-acquired pressure injuries (HAPIs). A total of 533 adult patients were followed over 2574 critical care days (mean age 62.4, standard deviation (SD) 14.3 years, mean body mass index 30.4 (SD 7.4) kg/m2, 36.4% female). This was a secondary analysis of prospective, non-randomised clinical data from an intensive care unit at a large urban teaching hospital. Factors related to perfusion, specifically two or more infusions of vasopressors/inotropes, temporary mechanical circulatory support (MCS), extracorporeal membrane oxygenation, and durable MCS, were analysed to determine whether they were more strongly associated with HAPIs than immobility due to prolonged mechanical ventilation (>72 h) or operating room time (>6 h). Patients diagnosed with a HAPI had a statistically significant higher risk of being exposed to variables related to perfusion and immobility (P < 0.05 for each variable). Perfusion-related variables, except durable MCS, had a larger effect on skin breakdown (number needed to harm (NNH) 4-10) than immobility-associated variables (NNH 12-17). The finding that perfusion-related variables predicted HAPIs may warrant consideration of alternative diagnoses, such as skin failure due to impaired perfusion as a pathophysiological process that occurs concurrently with multisystem organ failure. Differentiation of skin injuries primarily from circulatory malfunction, rather than external pressure, may guide the development of more effective treatment and prevention protocols. This pilot study suggests that the contribution of perfusion to skin injuries should be explored further.

Demographic-based disparities in outcomes for adults with central line-associated bloodstream infections in the United States: a National Inpatient Sample database study (2016-2020).

Central line-associated bloodstream infections (CLABSI) are prevalent and preventable hospital-acquired infections associated with high morbidity and costs. Disparities based on race, ethnicity, and hospital factors remain underexplored. This study compares cost, length of stay, and mortality for adults with CLABSI by race-ethnicity, hospital location-teaching status, and geographic region in the United States using data from the National Inpatient Sample (NIS) database from 2016 to 2020. The hospitalization cohort included adults diagnosed with CLABSI, excluding those with primary CLABSI diagnoses, cancer, immunosuppressed states, or neonatal conditions. Primary outcomes were in-hospital mortality, length of stay, and hospital costs, adjusted to mid-year 2020 US dollars. Independent variables included race-ethnicity, hospital location-teaching status, and geographic region. All analyses accounted for NIS sampling design. From 2016 to 2020, there were approximately 19,835 CLABSI hospitalizations. The overall in-hospital mortality rate was 9.1%, with a median hospital stay of 16.9 days and median cost of $44,810. Hispanic patients experienced significantly higher mortality, longer length of stay, and higher costs compared to non-Hispanic Black and White patients. Urban teaching hospitals had longer stays and higher costs than rural and urban non-teaching hospitals. Regionally, the Northeast and West had higher costs and longer stays than the Midwest and South, but mortality rates did not differ significantly. This study highlights significant disparities in CLABSI outcomes based on demographic factors. Addressing these disparities is crucial for improving CLABSI management and healthcare equity. Further research should explore the underlying causes of these differences to inform targeted interventions.

Socioeconomic Trends in Palliative Care: A Six-Year Study.

The use of palliative care (PC) is on the rise in the USA, with clear benefits to patients, families, hospitals, and insurance companies. Our study investigates trends in PC utilization, focusing on socioeconomic characteristics. The National Inpatient Sample (NIS) from 2015 to 2020 was used to identify adults hospitalized in the United States (US). International Classification of Diseases, Tenth Revision (ICD-10), was used for PC encounters, code Z51.5. An equal number of random records, stratified by year and without this code, were selected to serve as controls. Records were analyzed for baseline characteristics using a chi-square test. Adjusted odds ratios (ORs) of receiving PC were calculated using multivariate logistic regression. Men were more likely to receive PC consults (OR: 1.07, confidence interval (CI): 1.06-1.08). Medicare/Medicaid holders' PC access was limited compared to private insurance holders (0.89, 0.86-0.93). Racial minorities, particularly Hispanics (0.9, 0.86-0.95) and Blacks (0.83, 0.77-0.88), were less likely to engage in PC. Compared to urban teaching hospitals, rural hospitals had a decreased rate of PC utilization (0.53, 0.49-0.57). Smaller hospitals had significantly fewer PC referrals than large hospitals (0.80, 0.76-0.85). A lower socioeconomic status was associated with a reduced propensity to utilize PC services compared to an upper socioeconomic status (0.91, 0.87-0.96). Our analysis shows that socioeconomic factors strongly influence PC access. This highlights important inequities that require measures to improve equitable PC access across demographic groups.

Trends and Disparities in the Utilization of Thymectomy for Myasthenia Gravis in the United States.

In 2016, a randomized controlled trial demonstrated the clinical efficacy of trans-sternal thymectomy for patients with non-thymomatous myasthenia gravis (MG). Whether large-scale changes occurred in clinical practice after this trial is unknown. We performed a retrospective longitudinal cross-sectional analysis using National Inpatient Sample (NIS) data from 2012 to 2019. Our study included hospitalized adults at least 18 years of age diagnosed with MG without an associated thymoma. We used joinpoint regression to analyze annual trends in thymectomy volume and surgical approach (minimally invasive vs trans-sternal) from 2012 to 2019. Using logistic regression models, we examined patient and hospital-level factors that may have influenced whether thymectomy was performed, such as age, sex, race, insurance payor, hospital size and teaching status, and Elixhauser Comorbidity Index. Sampling weights were applied to account for the complex survey design of NIS. The total number of thymectomy procedures increased by 69.8% per year (95% CI 40.1-105.8) between 2012 and 2019. Trans-sternal thymectomies increased by 62.8% per year (95% CI 35.8-95.2) and minimally invasive thymectomies by 83.7% per year (95% CI 38.1-144.3). Thymectomies were significantly more likely to occur in 2017-2019 compared with 2012-2016 (OR 1.93, 95% CI 1.62-2.31). In a multivariable regression model, several factors decreased the odds of patients with MG having a thymectomy: older age, Black race (OR 0.62, 95% CI 0.49-0.77), female (OR 0.73, 95% CI 0.63-0.86), and higher Elixhauser Comorbidity Index. Patients in medium (OR 1.82, 95% CI 1.30-2.55) or large (OR 2.81, 95% CI 2.07-3.82) size and urban teaching hospitals (OR 6.09, 95% CI 2.65-13.97) were more likely to undergo thymectomy. Thymectomy is being performed more frequently for non-thymomatous MG, especially after 2016 after publication of a positive phase III clinical trial. There are several disparities in thymectomy utilization that warrant further attention.

Predicting falls with ultrasound, physical parameters or fall-risk questions among older adults: A prospective cohort study

BackgroundFalls are a significant issue among older adults, leading to morbidity and mortality. Screening for fall risk in the ED is crucial but challenging due to time limitations and patient conditions. Sarcopenia, characterized by muscle loss, is associated with increased fall risk, and ultrasound has been proposed as a non-invasive tool to measure muscle mass in this context. MethodsThis prospective cohort study enrolled 174 older adults from an urban teaching hospital's EDOU, assessing muscle mass via POCUS, grip strength, Timed Up and Go (TUG) test, and fall risk using the STEADI toolkit. The patients were followed up over six months to assess if they had fallen or not. ResultsFollow-up identified 37 participants (21 %) as patients who fell. There was no significant association between POCUS-measured muscle mass, grip strength, or TUG test performance with future falls. In contrast, STEADI questionnaire responses demonstrated significant differences between patients who fell and did not fall, suggesting its potential utility in predicting fall risk in this population. ConclusionThe simpler tool, the STEADI questionnaire, may offer more practicality in screening fall risk compared to complex ultrasound measurements or physical performance tests among the older in ED.

Outcomes of patients with acute pulmonary embolism managed in-house vs those transferred between hospitals: a retrospective observational study

BackgroundInterhospital transfer (IHT) for acute pulmonary embolism (PE) is increasingly performed to improve access to advanced reperfusion therapies. It is unclear if outcomes of patients undergoing IHT are comparable with those of patients presenting in-house to hospitals with PE Response Team (PERT) capabilities. ObjectivesTo determine whether outcomes of patients with acute PE undergoing IHT differ from those of patients presenting in-house. MethodsWe retrospectively reviewed 386 patients with acute PE who were treated by PERT at 1 of 3 urban teaching hospitals in the Mount Sinai Health System in New York City from January 2021 to October 2023. Propensity score–weighted analysis was performed to compare the outcomes of patients managed in-house with those of patients undergoing IHT. ResultsTwo hundred eighty-four patients presented in-house, while 102 were transferred from other hospitals. Median PE Severity Index score was 84, and 3 (0.8%), 80 (20.7%), 237 (61.4%), and 66 (17.1%) had low-risk, intermediate low–risk, intermediate high–risk, and high-risk PE. Odds of receiving systemic thrombolysis (odds ratio [OR], 1.06; P = .06) or advanced therapies (OR, 0.95; P = .003) were not significantly different between the 2 groups. Rates of 30-day mortality, major bleeding, and readmission were 6.9%, 2.9%, and 9.8% for the IHT group and 10.6%, 2.1%, and 13% for the in-house group, respectively. IHT patients had lower odds of 30-day mortality (OR, 0.88; P = .003) and higher odds of major bleeding (OR, 1.03; P = .04). ConclusionPERT-guided IHT for patients with acute PE was associated with reduced mortality but increased risk of bleeding compared with patients managed in-house at hospitals with PERT capabilities.

Comparative Outcomes of Peritoneal Dialysis across Different Hospital Settings: An Analysis of Urban Teaching, Urban Nonteaching, and Rural Hospitals

Comparative Outcomes of Peritoneal Dialysis across Different Hospital Settings: An Analysis of Urban Teaching, Urban Nonteaching, and Rural Hospitals

The Prevalence of Skin Tears in an Acute Care Hospital: A Quality Improvement Project.

The purpose of this quality improvement project was to determine the prevalence of skin tears (STs) within an acute care hospital. The setting was a 676-bed Midwestern urban teaching hospital with Magnet designation in the United States. All adult, children, and neonatal patients were assessed during the data collection period with the exclusion of the mother/baby unit and patients who were unsafe to move, actively dying, off the unit during the survey assessment, or those who declined participation. ST prevalence data were collected concurrently with the quarterly Pressure Injury Prevalence Survey over a period of 12-months (beginning the third quarter of 2017 through the second quarter of 2018) by the Pressure Injury Prevalence Survey Skin Care Champions using the revised Payne-Martin classification system for STs. A data collection form developed by the Wound, Ostomy, and Continence nurse was also completed for the patients with ST(s). The prevalence of STs was 2.92% (46/1576 patients). Twenty-one patients were women and 25 were men, with a mean age of 69.90years (age range: 8days-96years). The majority of STs were found on the extremities (60 STs, 86.96%) and hospital-acquired (30 patients, 65.22%). Thirty STs (43.48%) were category III according to the revised Payne-Martin classification system for STs with major risk factors identified as frail skin (n=34), advanced age (n=30), and impaired mobility (n=24). STs are a common finding in the acute care setting spanning all age groups and are frequently overlooked by health care providers. This project provides a strategy to determine ST prevalence in a health care setting. Additional studies should focus on risk factor assessment and prevention strategies as these may decrease the incidence of this painful wound.

Inpatient Complication Rates of Bronchoscopic Lung Volume Reduction in the United States

Early randomized controlled trials (RCTs) of bronchoscopic lung volume reduction (BLVR) have shown clinically meaningful benefits in lung function, dyspnea, and quality of life in patients with severe emphysema. Safety outcome data following BLVR in the US are scarce outside the RCTs. What is the rate of inpatient complications after BLVR in the real world in the US? We used The National In-patient Sample (NIS) database to identify in-hospital complications post-BLVR from 2018 to 2020. Complications were defined as pneumothorax, COPD exacerbation, pneumonia, hemoptysis, acute respiratory failure, and valve removal. We also analyzed all-cause in-hospital mortality and length of stay (LOS). We identified 467 admissions related to BLVR procedures. The number of procedures doubled between 2019 and 2020 (from 153 to 295 procedures). The median age was 67.9 years (IQR 61.1 - 72.8), 210 (45.0%) were female, 401 (85.8%) were white, and Medicare was the primary expected payer in 72.8% of cases. Most procedures were done in urban teaching hospitals (56.9%). The rate of pneumothorax was 26.3%, acute respiratory failure 19.5%, COPD exacerbation 8.8%, pneumonia 7.3%, and hemoptysis 5.3%. Chest tube placement was required in 84 out of 123 (68.3%) cases of pneumothorax. The endobronchial valve had to be removed in 69 cases (14.8%). The median LOS was 2.8 days (IQR 2.3 -4.5). The number of in-hospital deaths was less than 11 cases (< 2.3%). Overall, the subgroup who had in-hospital complications did not differ significantly from the others in terms comorbidities, demographics, and hospital characteristics. The real-world complication rate after BLVR was similar to the published complication rates from early randomized clinical trials. In-hospital mortality was low, suggesting that aside from the commonly anticipated complications, BLVR is a safe treatment option for severe emphysema.

Implementing a Compliance Monitoring Process to Promote Chlorhexidine Gluconate Bathing and Hand Hygiene: An Initiative to Decrease Central Line–Associated Bloodstream Infections

Background Chlorhexidine gluconate (CHG) bathing has proven to reduce central line–associated bloodstream infections (CLABSI) in hospitalized patients. The aim of this study is to evaluate whether the implementation of a compliance monitoring process for CHG bathing and strict hand hygiene as part of the traditional CLABSI prevention bundle will reduce the overall hospital CLABSI standardized infection ratio (SIR). Methods A quasi-experimental study was conducted in intensive care and non-intensive care inpatient hospital units in an urban 361-bed teaching hospital in Western Pennsylvania. The pre-intervention period consisted of January–August 2021, the intervention period consisted of September–November 2021, and the post-intervention and sustainability period consisted of December 2021–June 2022. A compliance monitoring process for the initiation of a daily bath using a 4% CHG solution and strict hand hygiene surveillance was implemented as part of the standard CLABSI prevention bundle (which includes standardized insertion checklists and processes, daily necessity assessment, dressing change and integrity standards, five moments hand hygiene standards, CHG disk [Biopatch], end caps [Curos], and care of tubing). Outcomes A statistically significant increase in hand hygiene (p=&lt;0.001) and in CHG bathing compliance (p=0.014) helped reduce the overall hospital CLABSI SIR from 1.45 to 0.82, standing for an overall 43.4% decrease. Cost reduction was statistically significant (p=0.011) and was an estimated $1.4 million dollars in savings for the hospital. Next Steps Incorporate the compliance monitoring component for CHG bathing and hand hygiene as part of the best strategy for CLABSI bundle prevention within the healthcare system.

Glucometrics utilisation in an urban teaching hospital in ireland: current practice and future aims.

Dysglycaemia in hospitalised patients is associated with poorer clinical outcomes, including cardiovascular events, longer hospital stays, and increased risk of mortality. Therefore, glucose monitoring is necessary to achieve best outcomes. This audit assesses use of point-of-care (POC) blood glucose (BG) testing in Tallaght University Hospital (TUH) over an 8-day period. It evaluates compliance with international and TUH glucose monitoring protocols and determines frequency of diabetes team consultations for inpatient adults. Data from an 8-day period (12/03/2023-19/03/2023) were extracted from the TUH COBAS-IT system and analysed. Invalid tests were excluded. Hyperglycaemia was defined as ≥ 10mmol/L and hypoglycaemia as ≤ 3.9mmol/L. Persistent hyperglycaemia was defined as two BG results of ≥ 10mmol/L. A chart review was conducted on adult patients with persistent hyperglycaemia to assess for HbA1C results, diabetes diagnosis, and diabetes consult. 3,530 valid tests were included and analysed. 674 individual patients had tests done. 1,165 tests (33.00%) were hyperglycaemic and 75 (2.12%) were hypoglycaemic. 68.25% of adults with persistent hyperglycaemia had an HbA1C test performed or documented within three months. 42.71% of inpatient adults with persistent hyperglycaemia and a known diabetes diagnosis received a consult from the diabetes team. Increased adherence to hospital protocols for testing HbA1C in adults with persistent hyperglycaemia could improve treatment and clinical outcomes. Increased diabetes team consultation could facilitate appropriate treatment and improve patient outcomes in persistently hyperglycaemic adult patient populations.

"It's not just teaching for the sake of teaching anymore": a quality improvement project for online instruction in a hospital library.

Medical libraries had to swiftly change how instruction services were provided in response to the COVID-19 pandemic. This article describes a Quality Improvement (QI) project to assess one hospital library's move to virtual instructional services. Information was gathered via a survey to Canadian hospital library workers and a focus group with internal staff with instructional responsibilities. Moving to online instruction increased audience attendance and garnered positive feedback, however library instructors report experiencing uncertainty about quality and effectiveness of online instruction. The article concludes with a description of planned actions to improve online instructional services in an urban research and teaching hospital library environment.

Outcomes of Acute Kidney Injury among Hospitalized Patients with Infective Endocarditis: A National Inpatient Sample Analysis.

Background/Objectives: Patients with infective endocarditis (IE) are more susceptible to acute kidney injury (AKI). The presence of AKI increases in-hospital complications in these patients. Methods: The 2016-2020 National Inpatient Sample (NIS) database consisting of adult admissions with IE and AKI was utilized. The primary outcome was all-cause inpatient mortality. Secondary outcomes included fluid and electrolyte disorders, stroke, septic arterial embolism, septic shock, cardiogenic shock, valve surgery, vasopressor support, mechanical ventilation, length of stay (LOS), and total hospital charges. Results: Out of a total of 63,725 adult admissions with IE, 16,295 (25.5%) admissions had AKI. Patients with AKI were more likely to be males (63% vs. 57.6%, p < 0.001) and older (55.8 vs. 50.4, p < 0.001). A higher proportion of these patients were admitted to large hospitals (60.6 vs. 55.3%, p < 0.001) and urban teaching hospitals (81.9 vs. 75%, p < 0.001). Patients with AKI had higher LOS (17 ± 16.1 vs. 11.32 ± 11.7, p < 0.001) and hospital charges (USD 239,046.8 ± 303,977.3 vs. USD 124,857.6 ± 192,883.5, p < 0.001). Multivariable analysis showed higher odds of all-cause inpatient mortality (aOR: 2.22, 95% CI: 1.81-2.73, p < 0.001). They also had higher risk for fluid and electrolyte disorder (aOR: 2.31, 95% CI: 2.10-2.53, p < 0.001), septic arterial embolism (aOR: 1.61, 95% CI: 1.42-1.84, p < 0.001), septic shock (aOR: 3.78, 95% CI: 2.97-4.82, p < 0.001), cardiogenic shock (OR: 3.37, 95% CI: 2.65-4.28, p < 0.001), valve surgery (aOR: 1.52, 95% CI: 1.35-1.71, p < 0.001), vasopressor requirement (aOR: 1.99, 95% CI: 1.52-2.60, p < 0.001), and mechanical ventilation (aOR: 2.75, 95% CI: 2.33-3.24, p < 0.001). The association with stroke was elevated but not statistically significant. Conclusions: This large retrospective analysis demonstrated that patients with AKI and infective endocarditis had increased mortality, adverse hospital outcomes, increased LOS, and hospital costs.

Implementation of a Multimodal Enhanced Recovery Protocol in Ambulatory Anorectal Surgery: A Randomized Trial.

Few studies report outcomes for enhanced recovery pathways in ambulatory anorectal surgery. We hypothesize that an ambulatory anorectal enhanced recovery pathway with multimodal analgesia can reduce postoperative opioid use. To compare postoperative opioid use in patients undergoing ambulatory anorectal surgery who receive multimodal analgesia vs. standard of care without multimodal analgesia. A prospective randomized trial of patients undergoing elective anal fistula or hemorrhoid surgery from September 2018 to May 2022. Urban teaching hospital. Adults aged 18 to 70 undergoing elective anal fistula or hemorrhoid surgery from September 2018 to May 2022. Multimodal enhanced recovery pathway including pre- and postoperative non-opioid analgesia with oral acetaminophen, gabapentin and ketolorac. Primary endpoint was oral opioid use during the first postoperative week. Secondary endpoints included maximum pain and nausea scores, adverse events and emergency room or hospital admissions during the first 30 days postoperatively. Of the 109 enrolled patients, 20 were lost to follow-up. The remaining 89 patients had a median age of 38 (range, 20-67) years and included 41 (46%) females. There were no significant differences between the enhanced recovery protocol (Arm E) and non-enhanced recovery protocol (Arm NE) groups in terms of preoperative and surgical characteristics. The study primary endpoint, oral MME use during the first week, was significantly higher among patients in the NE arm (79 mg; range, 0-600) than patients in the E arm (8 mg; range, 0-390) (p = 0.002). On subgroup analysis, both fistula and hemorrhoid surgery patients assigned to the NE arm took significantly higher oral MME in the first week than patients in the E arm. There was no significant difference in secondary endpoints. Patients and providers were not blinded. Our findings are limited to hemorrhoid and fistula surgery and may not be applicable to other anorectal procedures. Enhanced recovery protocols including multimodal analgesia should be used in elective anal fistula and hemorrhoid surgery to decrease postoperative opioid use. See Video Abstract . ClinicalTrials.gov ID NCT03738904.

Plasmapheresis in ANCA-Associated Vasculitis with Active Kidney Involvement in the United States (2016-2020): A Cross-Sectional Study.

Plasmapheresis is currently recommended when antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) presents with severe kidney and/or lung involvement. This cross-sectional study aimed at describing characteristics of hospitalized patients diagnosed with AAV with severe kidney involvement undergoing plasmapheresis in the US. We defined the study population as adults hospitalized for active kidney involvement with a new diagnosis of AAV (by subtype or unspecified). We established the cohort from the 2016-2020 National Inpatient Sample by ICD-10-CM codes. In this cross-sectional study, we described demographic and clinical characteristics, associated inpatient procedures, lengths of stay, hospital costs, and disposition at discharge comparing patients treated and not treated with plasmapheresis. We identified a total of 975 cases of hospitalized AAV with acute kidney involvement in the US treated by plasmapheresis over the 5-year period. Demographic characteristics of patients who received plasmapheresis were similar to those in patients who did not (n=5670). There were no regional differences in the proportion of patients who received plasmapheresis; however, plasmapheresis was deployed more frequently among patients admitted to urban teaching hospitals relative to rural and non-teaching hospitals. Cases treated with plasmapheresis were more likely to have had acute kidney injury (AKI) (96% vs. 90%, p=0.0007), AKI requiring dialysis (52% vs 16%, p<0.001), hypoxia (40% vs. 16%, p<0.0001), and respiratory failure requiring mechanical ventilation (13% vs. 3%, p=0.0003). During 2016-2020, plasmapheresis was deployed in approximately 20% of patients being admitted for AAV and acute kidney involvement in the US. As standards of care and practice evolve, the role of plasmapheresis in the management of AAV with acute kidney involvement will require further study.