Cost-effectiveness of routine type and screens in select urological surgeries.

PURPOSE: To evaluate the cost-effectiveness of obtaining a preoperative type and screen (T/S) for common urologic procedures. METHODS: A decision tree model was constructed to track surgical patients undergoing two preoperative blood ordering strategies as follows: obtaining a preoperative T/S versus not doing so. The model was applied to the National (Nationwide) Inpatient Sample (NIS) data, from January 1, 2006 to September 30, 2015. Cost estimates for the model were created from combined patient-level data with published costs of a T/S, type and crossmatch (T/C), a unit of pRBC, and one unit of emergency-release transfusion (ERT). The primary outcome was the incremental cost per ERT prevented, expressed as an incremental cost-effectiveness ratio (ICER) between the two preoperative blood ordering strategies. A cost-effectiveness analysis determined the ICER of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500.00. RESULTS: A total of 4,113,144 surgical admissions from 2006 to 2015 were reviewed. The overall transfusion rate was 10.54% (95% CI, 10.17-10.91) for all procedures. The ICER of preoperative T/S was $1500.00 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S. CONCLUSION: Routine preoperative T/S for radical prostatectomy (rate = 3.88%) and penile implants (rate = .91%) does not represent a cost-effective practice for these surgeries. It is important for urologists to review their institution T/S policy to reduce inefficiencies within the preoperative setting.

Cost-Effectiveness of Routine Type and Screens in Select Endonasal Skull Base Surgeries.

Objective The study aimed to evaluate the cost-effectiveness of obtaining preoperative type and screens (T/S) for common endonasal skull base procedures, and determine patient and hospital factors associated with receiving blood transfusions. Study Design Retrospective database analysis of the 2006 to 2015 National (nationwide) Inpatient Sample and cost-effectiveness analysis. Main Outcome Measures Multivariate regression analysis was used to identify factors associated with transfusions. A cost-effectiveness analysis was then performed to determine the incremental cost-effectiveness ratio (ICER) of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500. Results A total of 93,105 cases were identified with an overall transfusion rate of 1.89%. On multivariate modeling, statistically significant factors associated with transfusion included nonelective admission (odds ratio [OR]: 2.32; 95% confidence interval [CI]: 1.78-3.02), anemia (OR: 4.42; 95% CI: 3.35-5.83), coagulopathy (OR: 4.72; 95% CI: 2.94-7.57), diabetes (OR: 1.45; 95% CI: 1.14-1.84), liver disease (OR: 2.37; 95% CI: 1.27-4.43), pulmonary circulation disorders (OR: 3.28; 95% CI: 1.71-6.29), and metastatic cancer (OR: 5.85; 95% CI: 2.63-13.0; p < 0.01 for all). The ICER of preoperative T/S was $3,576 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S. Conclusion Routine preoperative T/S does not represent a cost-effective practice for these surgeries using nationally representative data. A selective T/S policy for high-risk patients may reduce costs.

The Impact of Month on Joint Arthroplasty In-Hospital Outcomes: The December Effect.

Background: The purpose of this study was to assess the impact of month of the year on postsurgical outcomes after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) and to specifically analyze for a December effect. Material and methods: The National Inpatient Sample was used to identify all patients older than 40 years undergoing primary TKA and THA between 2006 and 2015. Patients were stratified based on the month of the year of surgery. In-hospital complication, disposition, and economic outcomes were comparatively analyzed. Results: There were statistically significant differences in outcomes based on month of the year. When comparing December to the other months, both TKA and THA patients had significantly lower rates of any complication, postoperative anemia, and genitourinary complications, while there were significantly higher rates of home than rehab discharge and shorter average length of stay in December. THA patients additionally had significantly lower rates of cardiac and respiratory complications during December. Conclusion: Postoperative outcomes are significantly associated with the month in which arthroplasty is performed. This study provides evidence of a positive "December effect" of improved in-hospital complications and economic outcomes for surgeries performed in December. Future research should direct attention to the impact that social factors may have on outcomes after elective surgical procedures and how these factors may be translated to other months.

Clostridioides difficile infection after appendectomy: An analysis of short-term outcomes from the NSQIP database.

BACKGROUND: Clostridioides difficile infection can be a significant complication in surgical patients. The purpose of this study was to describe the incidence and impact on outcomes of Clostridioides difficile infection in adult patients after appendectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program data set was used to identify all patients with the primary procedure code of appendectomy between 2016 and 2018. Patient demographics and clinical characteristics were extracted from the database, and descriptive statistics were performed. A multivariate logistic regression was created to identify predictors of Clostridioides difficile infection following appendectomy. RESULTS: A total of 135,272 patients who underwent appendectomy were identified, and of those, 469(0.35%) developed Clostridioides difficile infection. Patients with Clostridioides difficile infection were more likely to be older (51.23 vs 40.47 years; P < .0001), female (P = .004), American Society of Anesthesiology score >2 (P < .0001), present with septic shock (P < .0001), or lack functional independence (P < .0001). Patients with Clostridioides difficile infection were more likely to have increased operative time (62.9 vs 50.4 minutes; P < .0001), have perforated appendicitis (48.9% vs 23.5%; P < .0001), and underwent open surgery (7.0% vs 4.0%; P = .0006). Postoperatively, patients with Clostridioides difficile infection required a longer length of stay (4.8 vs 1.8 days; P < .0001), had increased mortality (2.1% vs 0.1%; P < .0001), higher incidences of postoperative abscess (14.9% vs 2.9%; P < .0001), postoperative sepsis (15.1% vs 4.0%; P < .0001), and readmission (30.7% vs 3.4%; all P < .0001). On multivariate analysis, older age (P < .0001), female sex (P = .0043), septic shock (P = .0002), open surgery (P = .037), and dirty wound class (P = .0147) were all independently predictive factors of Clostridioides difficile infection after appendectomy. CONCLUSION: Clostridioides difficile infection is an uncommon postoperative complication of appendectomy and is associated with worse outcomes and higher mortality. Older patients, female sex, those with sepsis, and those undergoing open surgery are at higher risk for developing Clostridioides difficile infection.

Discordance among Belief, Practice, and the Literature in Infection Prevention in the NICU.

This study evaluates practices of infection control in the NICU as compared with the available literature. We aimed to assess providers' awareness of their institutional policies, how strongly they believed in those policies, the correlation between institution size and policies adopted, years of experience and belief in a policy's efficacy, and methods employed in the existing literature. An IRB-approved survey was distributed to members of the AAP Neonatal Section. A systematic review of the literature provided the domains of the survey questions. Data was analyzed as appropriate. A total of 364 providers responded. While larger NICUs were more likely to have policies, their providers are less likely to know them. When a policy is in place and it is known, providers believe in the effectiveness of that policy suggesting consensus or, at its worst, groupthink. Ultimately, practice across the US is non-uniform and policies are not always consistent with best available literature. The strength of available literature is adequate enough to provide grade B recommendations in many aspects of infection prevention. A more standardized approach to infection prevention in the NICU would be beneficial and is needed.

High-dose intravenous vitamin C decreases rates of mechanical ventilation and cardiac arrest in severe COVID-19.

Intravenous vitamin C (IV-VitC) has been suggested as a treatment for severe sepsis and acute respiratory distress syndrome; however, there are limited studies evaluating its use in severe COVID-19. Efficacy and safety of high-dose IV-VitC (HDIVC) in patients with severe COVID-19 were evaluated. This observational cohort was conducted at a single-center, 530 bed, community teaching hospital and took place from March 2020 through July 2020. Inverse probability treatment weighting (IPTW) was utilized to compare outcomes in patients with severe COVID-19 treated with and without HDIVC. Patients were enrolled if they were older than 18 years of age and were hospitalized secondary to severe COVID-19 infection, indicated by an oxygenation index < 300. Primary study outcomes included mortality, mechanical ventilation, intensive care unit (ICU) admission, and cardiac arrest. From a total of 100 patients enrolled, 25 patients were in the HDIVC group and 75 patients in the control group. The average time to death was significantly longer for HDIVC patients (P = 0.0139), with an average of 22.9 days versus 13.7 days for control patients. Patients who received HDIVC also had significantly lower rates of mechanical ventilation (52.93% vs. 73.14%; ORIPTW = 0.27; P = 0.0499) and cardiac arrest (2.46% vs. 9.06%; ORIPTW = 0.23; P = 0.0439). HDIVC may be an effective treatment in decreasing the rates of mechanical ventilation and cardiac arrest in hospitalized patients with severe COVID-19. A longer hospital stay and prolonged time to death may suggest that HDIVC may protect against clinical deterioration in severe COVID-19.

Efficacy of a pharmacist-managed diabetes clinic in high-risk diabetes patients, a randomized controlled trial - "Pharm-MD" : Impact of clinical pharmacists in diabetes care.

BACKGROUND: Diabetes mellitus affects 13% of American adults. To address the complex care requirements necessary to avoid diabetes-related morbidity, the American Diabetes Association recommends utilization of multidisciplinary teams. Research shows pharmacists have a positive impact on multiple clinical diabetic outcomes. METHODS: Open-label randomized controlled trial with 1:1 assignment that took place in a single institution resident-run outpatient medicine clinic. Patients 18-75 years old with type 2 diabetes mellitus and most recent HbA1c ≥9% were randomized to standard of care (SOC) (continued with routine follow up with their primary provider) or to the SOC + pharmacist-managed diabetes clinic PMDC group (had an additional 6 visits with the pharmacist within 6 months from enrollment). Patients were followed for 12 months after enrollment. Data collected included HbA1c, lipid panel, statin use, blood pressure control, immunization status, and evidence of diabetic complications (retinopathy, nephropathy, neuropathy). Intention-to-treat and per-protocol analysis were performed. RESULTS: Forty-four patients were enrolled in the SOC + PMDC group and 42 patients in the SOC group. Average decrease in HbA1c for the intervention compared to the control group at 6 months was - 2.85% vs. -1.32%, (p = 0.0051). Additionally, the odds of achieving a goal HbA1c of ≤8% at 6 months was 3.15 (95% CI = 1.18, 8.42, p = 0.0222) in the intervention versus control group. There was no statistically significant difference in the remaining secondary outcomes measured. CONCLUSIONS: Addition of pharmacist managed care for patients with type 2 diabetes mellitus is associated with significant improvements in HbA1c compared with standard of care alone. Missing data during follow up limited the power of secondary outcomes analyses. TRIAL REGISTRATION: ClinicalTrials.gov , ID: NCT03377127 ; first posted on 19/12/2017.

Twitter Engagement of Medical Students Applying to Urology Residency During COVID-19: A Mixed Methods Study.

OBJECTIVE: To determine how medical students' Twitter engagement impacted the urology residency match and overall student perception of Twitter. METHODS: We utilized a mixed methods approach with (1) Twitter metrics data, (2) online student surveys, and (3) qualitative semi-structured interviews. Interviews were evaluated with iterative thematic content analysis, while quantitative data were analyzed with descriptive statistics, and univariate analyses. RESULTS: We identified 245 Twitter accounts of Urology residency applicants from the 2021 cycle. Matched students were more likely to have a Twitter account (59% matched vs 28% unmatched, P = .002) and account creation increased following the COVID-19 pandemic announcement. Matched students' profiles were associated with more followers, bios mentioning Urology, home Urology residency programs, and no international flags and/or references. The online survey had a 16% response rate. A majority reported utilizing Twitter for residency information (95%), wanting to continue Twitter throughout residency (67%), and feeling uncomfortable tweeting about racial, political, or diversity issues (64%). Nine interviews revealed 4 themes: Twitter's opportunities for networking, Twitter's role in the application process, the burden of social media use, and professionalism. CONCLUSION: Students applying to Urology residency increasingly utilized Twitter during the COVID-19 pandemic and having a Twitter account was associated with matching. While Twitter may not be necessary to succeed in the match and can pose an additional time burden, applicants view it as an opportunity for learning, networking, and personal branding.

A prospective sonographic evaluation of peripheral intravenous catheter associated thrombophlebitis.

OBJECTIVE: Thrombophlebitis associated with peripheral intravenous catheters (PIVCs) is a poorly described complication in the literature. Given limited accuracy of current assessment tools and poor documentation in the medical record, the true incidence and relevance of this complication is misrepresented. We aimed to identify risk factors in the development of thrombophlebitis using an objective methodology coupling serial diagnostic ultrasound and clinical assessment. METHODS: We conducted a single-site, prospective observational cohort study. Adult patients presenting to the emergency department that underwent traditionally placed PIVC insertion and were being hospitalized with an anticipated length of stay greater than 2 days were eligible participants. Using serial, daily ultrasound evaluations and clinical assessments via the phlebitis scale, we identified patients with asymptomatic and symptomatic thrombosis. The primary goal was to identify demographic, clinical, and IV related risk factors associated with thrombophlebitis. Univariate and multivariate analyses were employed to identify risk factors for thrombophlebitis. RESULTS: A total of 62 PIVCs were included between July and August 2020. About 54 (87.10%) developed catheter-related thrombosis with 22 (40.74%) of the thrombosed catheters were characterized as symptomatic. Multivariate cox regression demonstrated that catheter diameter relative to vein diameter greater than one-third [AHR = 5.41 (1.91, 15.4) p = 0.0015] and angle of distal tip of catheter against vein wall ⩾5° [AHR = 4.39 (1.39, 13.8) p = 0.0116] were associated with increased likelihood of thrombophlebitis. CONCLUSIONS: Our study found that the increased proportion of catheter relative to vein size and steeper catheter tip angle increased the risk of thrombophlebitis. Catheter size relative to vein size is a modifiable factor that should be considered when inserting PIVCs. Additional larger prospective investigations using objective methodologies are needed to further characterize complications in PIVCs.

Social Determinants of Health Correlating with Mechanical Ventilation of COVID-19 Patients: A Multi-Center Observational Study.

IMPORTANCE: Several studies have relayed the disproportionate impact of COVID-19 on marginalized communities; however, few have specifically examined the association between social determinants of health and mechanical ventilation (MV). OBJECTIVE: To determine which demographics impact MV rates among COVID-19 patients. DESIGN: This observational study included COVID-19 patient data from eight hospitals' electronic medical records (EMR) between February 25, 2020, to December 31, 2020. Associations between demographic data and MV rates were evaluated using uni- and multivariate analyses. SETTING: Multicenter (eight hospitals), largest health system in Southeast Michigan. PARTICIPANTS: Inpatients with a positive RT-PCR for SARS-CoV-2 on nasopharyngeal swab. Exclusion criteria were missing demographic data or non-permanent Michigan residents. EXPOSURE: Patients were divided into two groups: MV and non-MV. MAIN OUTCOME AND MEASURES: The primary outcome was MV rate per demographic. A multivariate model then predicted the odds of MV per demographic descriptor. Hypotheses were formulated prior to data collection. RESULTS: Among 11,304 COVID-19 inpatients investigated, 1621 (14.34%) were MV, and 49.96% were male with a mean age of 63.37 years (17.79). Significant social determinants for MV included Black race (40.19% MV vs 31.31% non-MV, p<0.01), poverty (14.60% vs. 13.21%, p<0.01), and disability (12.65% vs 9.14%; p<0.01). Black race (AOR 1.61 (CI 1.41-1.83; p<0.01)), median income (AOR 0.99 (CI 0.99-0.99; p<0.01)), disability (AOR 1.55 (CI 1.26, 1.90; p<0.01)), and non-English-speaking status (AOR 1.26 (CI 1.05, 1.53)) had significantly higher odds of MV. CONCLUSIONS AND RELEVANCE: Black race, low socioeconomic status, disability, and non-English-speaking status were significant risk factors for MV from COVID-19. An urgent need remains for a pandemic response program that strategizes care for marginalized communities.

Prediabetes as a risk factor for major adverse cardiovascular events.

INTRODUCTION: Type II diabetes mellitus (DM) is a proinflammatory process and a known risk factor for major adverse cardiac events (MACE). The same inflammatory markers may be present in prediabetes (pDM); however, the relationship between pDM by HbA1c and MACE is not well studied. We sought to see if pDM increases one's risk for MACE. METHODS: We retrospectively studied patients at Beaumont Health, Michigan between 2006 and 2020. We divided patients into groups (G1-G5) based on haemoglobin A1c (HbA1c) trends over the study period as follows: G1: pDM patients who remained pDM; G2: pDM who progressed into DM; G3: pDM who normalized their HbA1c; G4: patients who maintained a normal HbA1c; and G5: patients with HbA1c persistently in the DM range. We compared MACE between the groups by univariate and multivariate regression analyses. RESULTS: A total of 119,271 patients were included in the study (G1: N = 13,520, G2: N = 6314, G3: N = 1585, G4: N = 15,018, G5: N = 82,834). Pairwise comparison revealed a statistically significant increase in the odds of MACE in all groups compared to those with normal HbA1c values (G4; p < .001). After adjusting for baseline characteristics, multivariate regression revealed elevated odds of MACE in patients with persistent pDM (G1; aOR = 1.087, p = .002) and diabetes (G2/G5; aOR = 1.25 and aOR = 1.18, p < .001) compared to individuals with normal HbA1c values. CONCLUSION: Prediabetes is a risk factor for MACE. Normalization of HbA1c values appears to decrease the adjusted risk for MACE and should be the goal in patients with pDM.KEY MESSAGESPatients with prediabetes (pDM) are at increased risk for major cardiovascular events.Normalization of HbA1c in pDM patients may have a clinically significant benefit, in terms of lowering the MACE risk.Prediabetes patients who progress into diabetes mellitus may represent a particularly high-risk group.

The Impact of Disparities in Social Determinants of Health on Hospitalization Rates for Patients with COVID-19 in Michigan (USA).

IMPORTANCE: The COVID-19 pandemic continues to impact the health-care system in the United States and has brought further light on health disparities within it. However, only a few studies have examined hospitalization risk with regard to social determinants of health. OBJECTIVE: We aimed to identify how health disparities affect hospitalization rates among patients with COVID-19. DESIGN: This observational study included all individuals diagnosed with COVID-19 from February 25, 2020 to December 31, 2020. Uni- and multivariate analyses were utilized to evaluate associations between demographic data and inpatient versus outpatient status for patients with COVID-19. SETTING: Multicenter (8 hospitals), largest size health system in Southeast Michigan, a region highly impacted by the pandemic. PARTICIPANTS: All outpatients and inpatients with a positive RT-PCR for SARS-CoV-2 on nasopharyngeal swab were included. Exclusion criteria included missing demographic data or status as a non-permanent Michigan resident. EXPOSURE: Patients who met inclusion and exclusion criteria were divided in 2 groups: outpatients and inpatients. MAIN OUTCOME AND MEASURES: We described the comparative demographics and known disparities associated with hospitalization status. RESULTS: Of 30,292 individuals who tested positive for SARS-CoV-2, 34.01% were admitted to the hospital. White or Caucasian race was most prevalent (57.49%), and 23.35% were African-American. The most common ethnicity was non-Hispanic or Latino (70.48%). English was the primary language for the majority of patients (91.60%). Private insurance holders made up 71.11% of the sample. Within the hospitalized patients, lower socioeconomic status, African-American race and Hispanic and Latino ethnicity, non-English speaking status, and Medicare and Medicaid were more likely to be admitted to the hospital. CONCLUSIONS AND RELEVANCE: Several health disparities were associated with greater rates of hospitalization due to COVID-19. Addressing these inequalities from an individual to system level may improve health-care outcomes for those with health disparities and COVID-19.

Anxiety and Depression Impact on Inhospital Complications and Outcomes After Total Knee and Hip Arthroplasty: A Propensity Score-Weighted Retrospective Analysis.

INTRODUCTION: The purpose of this study was to assess the impact of anxiety and depression on immediate inhospital outcomes and complications after total joint arthroplasty of the hip (total hip arthroplasty [THA]) and knee (total knee arthroplasty [TKA]) using a large national registry. METHODS: Data from the National Inpatient Sample was used to identify all patients undergoing TKA and THA between 2006 and 2015. Patients were divided in four groups based on a concomitant diagnosis of depression, anxiety, depression plus anxiety, and neither depression nor anxiety (control group). Propensity score analysis was performed to determine whether these psychiatric comorbidities were risk factors for inhospital economic, disposition, and complication outcomes. RESULTS: A total of 5,901,057 TKAs and 2,838,742 THAs were performed in our study period. The relative percentage of patients with anxiety and depression undergoing these procedures markedly increased over time. All three psychiatric comorbidity groups were markedly associated with an increased risk of postoperative anemia and were markedly associated with other inhospital complications compared with the control group. Notable associations were also found between the study groups and total charges, length of stay, and disposition. DISCUSSION: Anxiety and depression are major risk factors for inhospital complications and are markedly associated with economic and disposition outcomes after TKA and THA. The relative proportion of patients with anxiety and depression undergoing these procedures is rapidly increasing. It is critical for clinicians to remain aware of these risk factors, and attention should be directed on the development of standardized perioperative optimization protocols and medication management for these patients. LEVEL OF EVIDENCE: Level III, retrospective study.

Healthcare Disparities Correlated with In-Hospital Mortality in COVID-19 Patients.

INTRODUCTION: Increasing age, male gender, African American race, and medical comorbidities have been reported as risk factors for COVID-19 mortality. We aimed to identify health-care disparities associated with increased mortality in COVID-19 patients. METHODS: We performed an observational study of all hospitalized patients with SARS-CoV2 infection from within the largest multicenter healthcare system in Southeast Michigan, from February to December, 2020. RESULTS: From 11,304 hospitalized patients, 1295 died, representing an in-hospital mortality rate of 11.5%. The mean age of hospitalized patients was 63.77 years-old, with 49.96% being males. Older age (AOR = 1.05, p < 0.0001), male gender (AOR = 1.43, p < 0.0001), divorced status (AOR = 1.25, p = 0.0256), disabled status (AOR = 1.42, p = 0.0091), and homemakers (AOR = 1.96, p = 0.0216) were significantly associated with in-hospital mortality. CONCLUSION: Older age, male gender, divorced and disabled status and homemakers were significantly associated with in-hospital mortality if they developed COVID-19. Further research should aim to identify the underlying factors driving these disparities in COVID-19 in-hospital mortality.

Trends, survival outcomes, and predictors of nonadherence to mastectomy guidelines for nonmetastatic inflammatory breast cancer.

BACKGROUND: The Current National Comprehensive Cancer Network guidelines recommend modified radical mastectomy (MRM) as the surgical treatment of choice for nonmetastatic inflammatory breast cancer (IBC). Limited studies have looked into the outcomes of breast conserving surgery (BCS) vs. MRM for IBC. METHODS: National Cancer Database (NCDB) data from 2004 to 2014 were retrospectively analyzed. Patients' demographics, tumor characteristics, and overall survival (OS) trends were compared for BCS and MRM cases of nonmetastatic IBC. Univariate and multivariate analyses were performed. RESULTS: A total of 413 (3.89%) BCS and 10,197 (96.11%) MRM cases were identified. Median follow-up was 58.45 months. Compared to MRM, BCS patients were more likely to be older, be African American, have Medicare/Medicaid or be uninsured, live in lower education ZIP codes, and live in a metropolitan area (all p < 0.05). BCS rates significantly decreased from 5.84% in 2004 to 3.19% in 2014 (p < 0.001). BCS patients also were more likely to have less than 50% of the breast involved (51.57% vs. 43.88%; p = 0.0081) and were less likely to receive trimodal therapy (50.85% vs. 74.62%; p = <0.0001). The OS was significantly higher in the mastectomy group over 9 years at 62.02% vs. 54.47% in the BCS group. Additionally, in the adjusted multivariate model, BCS cases were associated with 23% higher hazards of overall mortality (p = 0.0091). CONCLUSION: BCS was performed in a limited number of cases, which decreased over the study period. The analysis identified both demographic predictors of receiving BCS and significantly lower OS for IBC patients undergoing a BCS.

Early recognition of peripheral intravenous catheter failure using serial ultrasonographic assessments.

OBJECTIVE: Peripheral intravenous catheter (PIVC) failure occurs frequently, but the underlying mechanisms of failure are poorly understood. We aim to identify ultrasonographic factors that predict impending PIVC failure prior to clinical exam. METHODS: We conducted a single site prospective observational investigation at an academic tertiary care center. Adult emergency department (ED) patients who underwent traditional PIVC placement in the ED and required admission with an anticipated hospital length of stay greater than 48 hours were included. Ongoing daily PIVC assessments included clinical and ultrasonographic evaluations. The primary objective was to identify ultrasonographic PIVC site findings associated with an increased risk of PIVC failure. The secondary outcome was to determine if ultrasonographic indicators of PIVC failure occurred earlier than clinical recognition of PIVC failure. RESULTS: In July and August of 2020, 62 PIVCs were enrolled. PIVC failure occurred in 24 (38.71%) participants. Multivariate logistic regression demonstrated that the presence of ultrasonographic subcutaneous edema [AOR 7.37 (1.91, 27.6) p = 0.0030] was associated with an increased likelihood of premature PIVC failure. Overall, 6 (9.67%) patients had subcutaneous edema present on clinical exam, while 35 (56.45%) had subcutaneous edema identified on ultrasound. Among patients with PIVC failure, average time to edema detectable on ultrasound was 46 hours and average time to clinical recognition of failure was 67 hours (P = < 0.0001). CONCLUSIONS: Presence of subcutaneous edema on ultrasound is a strong predictor of PIVC failure. Subclinical subcutaneous edema occurs early and often in the course of the PIVC lifecycle with a predictive impact on PIVC failure that is inadequately captured on clinical examination of the PIVC site. The early timing of this ultrasonographic finding provides the clinician with key information to better anticipate the patient's vascular access needs. Further research investigating interventions to enhance PIVC survival once sonographic subcutaneous edema is present is needed.

Impact of Clostridium difficile infection on pediatric appendicitis.

INTRODUCTION: Clostridium difficile is an important cause of nosocomial infection in the pediatric population. The purpose of this study is to estimate the impact of Clostridium difficile infection complicating pediatric acute appendicitis. METHODS: This study utilizes the combined 2009 and 2012 Kids' Inpatient Database. Statistical analysis is weighted and was done using Survey Sampling and Analysis procedures in SAS 9.4. RESULTS: We identified 176,934 cases with appendicitis and 0.2% (n = 358) had a concurrent diagnosis of C. difficile. The proportion of cases with C. difficile in perforated appendicitis was greater than in the non-perforated cases (0.39% vs. 0.06%; p < .01). Multivariate analysis showed that perforated appendicitis (OR 5.22), and anemia (OR 4.95) were independent predictors of C. difficile infection (p < .001). Adjusted for perforated appendicitis, cases with C. difficile had 4.78 days longer length of stay (LOS) and higher total charges of $29,887 (all p < 0.0001) compared to non-C. difficile cases. CONCLUSION: C. difficile infection is a rare, but impactful complication of pediatric appendicitis and is associated with greater disease severity. Proper antibiotic stewardship could minimize the risk of C. difficile in pediatric appendicitis.

Respiratory Modalities in Preventing Reintubation in a Pediatric Intensive Care Unit.

Post-extubation respiratory failure requiring reintubation in a Pediatric Intensive Care Unit (PICU) results in significant morbidity. Data in the pediatric population comparing various therapeutic respiratory modalities for avoiding reintubation is lacking. Our objective was to compare therapeutic respiratory modalities following extubation from mechanical ventilation. About 491 children admitted to a single-center PICU requiring mechanical ventilation from January 2010 through December 2017 were retrospectively reviewed. Therapeutic respiratory support assisted in avoiding reintubation in the majority of patients initially extubated to room air or nasal cannula with high-flow nasal cannula (80%) or noninvasive positive pressure ventilation (100%). Patients requiring therapeutic respiratory support had longer PICU LOS (10.92 vs 6.91 days, P-value = .0357) and hospital LOS (16.43 vs 10.20 days, P-value = .0250). Therapeutic respiratory support following extubation can assist in avoiding reintubation. Those who required therapeutic respiratory support experienced a significantly longer PICU and hospital LOS. Further prospective clinical trials are warranted.

Assessing the impact of resuscitation residents on the treatment of cardiopulmonary resuscitation patients.

BACKGROUND: The management of cardiac arrest patients receiving cardiopulmonary resuscitation (CPR) is an essential aspect of emergency medicine (EM) training. At our institution, we have a 1-month Resuscitation Rotation designed to augment resident training in managing critical patients. The objective of this study is to compare 30-day mortality between cardiac arrest patients with resuscitation resident (RR) involvement versus patients without. Our secondary outcome is to determine if RR involvement altered rates of initiating targeted temperature management (TTM). METHODS: This study was conducted at a single site tertiary care Level-1 trauma center with an Emergency Department (ED) census of nearly 130,000 visits per year. Data was collected from 01/01/2015 to 01/01/2018 using electronic medical records via query. Patients admitted with cardiac arrest were separated into two groups, one with RR involvement and one without. Initial rhythm of ventricular fibrillation/tachycardia (VFIB/VTACH), 30-day mortality, history of coronary artery disease (CAD), and initiation of TTM were compared. Statistical analysis was performed. RESULTS: Out of 885 patient encounters, 91 (10.28%) had RR participation. There was no statistical difference in 30-day mortality between patients with RR involvement compared to those without (71.42% vs 66.36%; P = 0.3613). However, TTM was initiated more in the RR group (20.70% vs 8.86%; P = 0.0025). Patients who received TTM also had a lower 30-day mortality compared to those without TTM (52.94% vs 70.87%; P = 0.0020). Patients who were older and had no history of CAD were also noted to have a statistically significant higher 30-day mortality. All other variables were not statistically significant. CONCLUSION: Resuscitation resident involvement with the care of cardiac arrest patients had no impact in 30-day mortality. However, the involvement of RR was associated with a statistically significant increase in the initiation of TTM. One limitation is that RR participated in 10.28% of the cases analyzed herein, thus the two arms are unbalanced in size. Future work may investigate if the increase in TTM in the RR involved cases may portend improved rates of neurologically intact survival or more rapid achievement of goal temperatures.

Industry-Sponsored Research Payments in Neurosurgery-Analysis of the Open Payments Database From 2014 to 2018.

BACKGROUND: The Open Payments Database (OPD) started in 2013 to combat financial conflicts of interest between physicians and medical industry. OBJECTIVE: To evaluate the first 5 yr of the OPD regarding industry-sponsored research funding (ISRF) in neurosurgery. METHODS: The Open Payments Research Payments dataset was examined from 2014 to 2018 for payments where the clinical primary investigator identified their specialty as neurosurgery. RESULTS: Between 2014 and 2018, a $106.77 million in ISRF was made to 731 neurosurgeons. Fewer than 11% of neurosurgeons received ISRF yearly. The average received $140 000 in total but the median received $30,000. This was because the highest paid neurosurgeon received $3.56 million. A greater proportion ISRF was made to neurosurgeons affiliated with teaching institutions when compared to other specialties (26.74% vs 20.89%, P = .0021). The proportion of the total value of ISRF distributed to neurosurgery declined from 0.43% of payments to all specialties in 2014 to 0.37% in 2018 (P < .001), but no steady decline was observed from year to year. CONCLUSION: ISRF to neurosurgeons comprises a small percentage of research payments made to medical research by industry sponsors. Although a greater percentage of payments are made to neurosurgeons in teaching institutions compared to other specialties, the majority is given to neurosurgeons not affiliated with a teaching institution. A significant percentage of ISRF is given to a small percentage of neurosurgeons. There may be opportunities for more neurosurgeons to engage in industry-sponsored research to advance our field as long as full and complete disclosures can always be made.