Implementation of an Atrial Fibrillation Decision Aid Care Pathway in the Emergency Department Reduces Atrial Fibrillation Hospitalizations.

BACKGROUND: A straightforward decision aid to guide disposition of atrial fibrillation (AF) patients in the emergency department (ED) was developed for use by ED providers. The implementation of this decision aid in the ED has not been studied. METHODS: A pragmatic stepped-wedge cluster approach for analysis of retrospectively collected electronic health record data was used in which 5 hospitals were selected to commence the intervention at periodic intervals following an initial 1-year baseline assessment with 5 additional hospitals included in the comparison group (all in North Carolina). The primary end point of analysis was hospitalization rate. Hierarchical multivariable logistic regression analyses for admission as a function of the intervention while controlling for prespecified patient and hospital predictors were performed with clustering done at the hospital level. RESULTS: Between October 2017 and May 2020, a total of 11 458 patients (mean age, 71.4; 50.5% female) presented to 1 of the 10 hospitals with a primary diagnosis of AF. Absolute admission rate was reduced from 60.5% to 48.3% following the intervention (odds ratio, 0.83 [95% CI, 0.71-0.97]; P=0.016). After adjusting for covariates, the intervention was associated with a small increased rate of return to the ED for AF within 30 days of the initial presentation (1.6% to 2.7%; hazard ratio, 1.70 [95% CI, 1.26-2.31]; P<0.001). CONCLUSIONS: We demonstrate that implementation of a novel decision aid to guide disposition of patients primary diagnosis of AF presenting to the ED was associated with a reduced admission rate independent of patient and hospital factors. Use of the protocol was associated with a small but significant increase in rate of repeat presentations for AF at 30-day follow-up. Use of a decision aid such as the one described here represents an important tool to reduce unnecessary AF hospitalizations.

Axillary Thermometry Demonstrates Greater Reliability Compared With Rectal Thermometry in Healthy Neonates.

Rectal thermometry (RT) is considered the gold standard for measuring temperature in newborns, despite increasing use of temporal artery thermometry (TT) and axillary thermometry (AT) methods. Few prospective studies compare RT, TT, and AT in a newborn nursery setting. To determine the accuracy and reliability of these methods, we enrolled 205 healthy, full-term newborns. TT displayed higher mean temperatures than RT by 0.25 °F (standard error [SE] = 0.04, P < .001). AT and RT measurements did not significantly differ, with their means differing only by 0.02 °F (SE = 0.04, P = .87). For reliability, RT measurements differed by 0.45 °F (SE = 0.03) in either direction of the models' predicted mean for each subject. AT and TT measurements varied much less from their predicted means 0.32 °F (SE = 0.02) and 0.34 °F (SE = 0.02), respectively (both P < .001). Assuming mean RT is correct, TT is less accurate than AT. RT showed poor reliability between measurements. AT is an accurate and reliable method of temperature screening in healthy neonates.

Systematic Quality Improvement and Metabolic Monitoring for Individuals Taking Antipsychotic Drugs.

OBJECTIVE: The authors sought to increase the rate of cardiometabolic monitoring for patients receiving antipsychotic drugs in an academic outpatient psychiatric clinic serving people with serious mental illness. METHODS: Using a prospective quasi-experimental, interrupted time-series design with data from the electronic health record (EHR), the authors determined metabolic monitoring rates before, during, and after implementation of prespecified quality improvement (QI) measures between August 2016 and July 2017. QI measures included a combination of provider, patient, and staff education; systematic barrier reduction; and an EHR-based reminder system. RESULTS: After 1 year of QI implementation, the rate of metabolic monitoring had increased from 33% to 49% (p<0.01) for the primary outcome measure (hemoglobin A1C and lipid panel). This increased monitoring rate was sustained for 27 months beyond the end of the QI intervention. More than 75% of providers did not find the QI reminders burdensome. CONCLUSIONS: Significant improvement in the rate of metabolic monitoring for people taking antipsychotic drugs can be achieved with little added burden on providers. Future research needs to assess the full range of patient, provider, and system barriers that prevent cardiometabolic monitoring for all individuals receiving antipsychotic drugs.

Peptide Amphiphile Supramolecular Nanostructures as a Targeted Therapy for Atherosclerosis.

The rising prevalence of cardiovascular disease worldwide necessitates novel therapeutic approaches to manage atherosclerosis. Intravenously administered nanostructures are a promising noninvasive approach to deliver therapeutics that reduce plaque burden. The drug liver X receptor agonist GW3965 (LXR) can reduce atherosclerosis by promoting cholesterol efflux from plaque but causes liver toxicity when administered systemically at effective doses, thus preventing its clinical use. The ability of peptide amphiphile nanofibers containing apolipoprotein A1-derived targeting peptide 4F to serve as nanocarriers for LXR delivery (ApoA1-LXR PA) in vivo is investigated here. These nanostructures are found to successfully target atherosclerotic lesions in a mouse model within 24 h of injection. After 8 weeks of intravenous administration, the nanostructures significantly reduce plaque burden in both male and female mice to a similar extent as LXR alone in comparison to saline-treated controls. Furthermore, they do not cause increased liver toxicity in comparison to LXR treatments, which may be related to more controlled release by the nanostructure. These findings demonstrate the potential of supramolecular nanostructures as safe, effective drug nanocarriers to manage atherosclerosis.

Findings From a Randomized Trial of Weight Gain Prevention Among Overweight Puerto Rican Young Adults.

OBJECTIVE: Assess impact of multimodality weight gain prevention intervention. METHODS: Randomized clinical trial among 39 overweight young Puerto Rico college students using 10 weekly peer-support sessions promoting dietary, physical activity, and other lifestyle changes enhanced by stress-reduction and mindfulness approaches. Body mass index (BMI) and self-reported behaviors were measured at baseline and at 10 weeks and 6 months after baseline. RESULTS: At the completion of the intervention, BMIs in the experimental arm were 0.8 units lower than at baseline (z = -3.0; P = .008) and 1.2 lower at 6 months after baseline (z = -4.1; P < .001); BMIs in the control arm were 0.7 higher (z = 2.7; P = .02) at 10 weeks and 0.8 higher at 6 months (z = 3.1; P = .005). Group × time interaction confirmed that BMI differed significantly over time between arms (χ2 = 26.9; degrees of freedom = 2; P < .001). Analysis of behavioral changes was mostly inconclusive although the experimental arm reported a considerable increase in walking at 10 weeks. Qualitative data suggested that yoga and mindfulness components were particularly useful for motivating participants to maintain healthier lifestyle patterns. CONCLUSIONS: Body mass index in the experimental arm decreased at the end of intervention and was maintained at 6 months' follow-up.

Antimicrobial activity of a continuous visible light disinfection system.

We evaluated the ability of high-intensity visible violet light with a peak output of 405 nm to kill epidemiologically important pathogens. The high irradiant light significantly reduced both vegetative bacteria and spores at some time points over a 72-hour exposure period.

Patients discharged from the emergency department after referral for hospitalist admission.

OBJECTIVES: To describe the characteristics and outcomes of patients discharged from the emergency department (ED) by hospitalist physicians. STUDY DESIGN: Retrospective cohort study at a tertiary academic medical center. METHODS: We used consultation Current Procedural Technology codes to identify patients discharged from the ED after referral for hospitalist admission from April 2011 to April 2014. We report patient demographics and primary diagnoses. Main outcome measures included return to the ED, hospitalization, or mortality, all within 30 days. RESULTS: There were 710 discharges from the ED for 670 patients referred for hospitalist admission; 21.7% returned to the ED, 12.3% were hospitalized, and 0.4% died within 30 days. Chest pain was the most common diagnosis (38.2%); 18.1% of these patients returned to the ED within 30 days. Patients with the following 3 diagnoses returned to the ED most frequently: sickle cell disease (82.4%), alcohol-related diagnoses (43.5%), and abdominal pain (35.7%). In multivariate analysis, abdominal pain (odds ratio [OR], 3.2; P <.001) and alcohol dependence (OR, 3.1; P = .003) increased the odds of ED revisits, whereas syncope (OR, 0.23; P = .049) reduced the odds. Chest pain reduced the odds of hospitalization (OR, 0.37; P = .005). CONCLUSIONS: A majority of patients discharged from the ED after referral for hospitalist admission did not return to the ED within 30 days, and the 30-day hospitalization rate was low. Our data suggest that hospitalists can safely aid patients by reducing the costs and adverse outcomes associated with unnecessary hospitalization.

The Effect of a Door Alarm on Operating Room Traffic During Total Joint Arthroplasty.

Operating room traffic has been implicated in several studies to contribute to the risk of surgical site infections and periprosthetic joint infections. The purpose of this study was to evaluate the effect of a door alarm on operating room traffic during total joint arthroplasty. This prospective cohort study evaluated 100 consecutive primary total hip and knee arthroplasty surgeries performed by a single surgeon. An inconspicuous electronic door counter was placed on the substerile operating room door. Door openings and time left ajar were recorded. After 50 cases, an audible alarm was placed on the substerile operating room door that sounded continuously when the door was ajar. Door-opening data were then recorded for an additional 50 cases. There was a significant difference in the overall mean door openings per minute (P<.001) between the period with no alarm (0.53±0.1) and with an alarm (0.42±0.1). This effect slowly decreased over the time of the intervention, with door openings per minute increasing by a factor of 1.01. The percentage of time the door was left ajar per case also decreased significantly (P<.001) with the alarm (6.63%±1.6%) compared with no alarm (8.65%±1.5%). This study indicates that the use of a door alarm can decrease door openings and potentially the risk for surgical site infection. However, the effect is subject to tolerance and may not result in the elimination of unnecessary operating room traffic long term. [Orthopedics. 2017; 40(6):e1081-e1085.].

A comparison of a homemade central line simulator to commercial models.

BACKGROUND: Simulation is quickly becoming vital to resident education, but commercially available central line models are costly and little information exists to evaluate their realism. This study compared an inexpensive homemade simulator to three commercially available simulators and rated model characteristics. MATERIALS AND METHODS: Seventeen physicians, all having placed >50 lines in their lifetime, completed blinded central line insertions on three commercial and one homemade model (made of silicone, tubing, and a pressurized pump system). Participants rated each model on the realism of its ultrasound image, cannulation feel, manometry, and overall. They then ranked the models based on the same variables. Rankings were assessed with Friedman's and post hoc Conover's tests, using alphas 0.05 and 0.008 (Bonferroni corrected), respectively. RESULTS: The models significantly differed (P < 0.0004) in rankings across all dimensions. The homemade model was ranked best on ultrasound image, manometry measurement, cannulation feel, and overall quality by 71%, 67%, 53%, and 77% of raters, respectively. It was found to be statistically superior to the second rated model in all (P < 0.003) except cannulation feel (P = 0.134). Ultrasound image and manometry measurement received the lowest ratings across all models, indicating less realistic simulation. The cost of the homemade model was $400 compared to $1000-$8000 for commercial models. CONCLUSIONS: Our data suggest that an inexpensive, homemade central line model is as good or better than commercially available models. Areas for potential improvement within models include the ultrasound image and ability to appropriately measure manometry of accessed vessels.

Analysis of anticoagulation strategies for venous thromboembolism during severe thrombocytopenia in patients with hematologic malignancies: a retrospective cohort.

The safety and efficacy of anticoagulation for venous thromboembolism (VTE) at times of severe thrombocytopenia is unclear. In this retrospective study, we evaluated patients with hematologic malignancy and either (1) acute or chronic VTE on anticoagulation before platelet count dropped below 50 × 109/L or (2) acute VTE occurring while platelets were <50 × 109/L. In 78 eligible patients, the primary outcomes of time to recurrent VTE or clinically significant bleeding within 100 d were compared by management strategy. Bleeding occurred in 27% of patients receiving anticoagulation versus 3% when anticoagulation was held (IRR 10.1, 95% CI 1.5-432.6). Recurrent VTE occurred in 2% of patients receiving anticoagulation versus 15% when anticoagulation was held (IRR 0.17, 95% CI 0.0-1.51). Most bleeding occurred before day 31(11/13), but recurrent VTE mostly occurred after day 40 (5/6). Our findings suggest that temporarily withholding anticoagulation for VTE during severe thrombocytopenia in patients with hematologic malignancies might reduce adverse outcomes.

Complications of Open Approaches to the Skull Base in the Endoscopic Era.

Objective It is important to characterize the developing complication profile of the open approach as it becomes reserved for more complex disease during the endoscopic era. Our objective was to characterize complication rates of current open skull base surgery. Design Retrospective chart review. Setting Tertiary care center. Participants The study group consisted of 103 patients and 117 open skull base surgeries were performed from 2008 to 2012. Main Outcome Measures Intraoperative/postoperative complications. Methods Fisher exact test and Wilcoxon rank sum test evaluated for associations of complications with potential risk factors. Results Postoperative complications occurred in 53 (45%) cases, of which 36 (31%) were major complications. Malignancy, dural grafting, age, and obesity were not associated with complications. Flap reconstruction was associated with increased complication rates (odds ratio = 2.27; 95% confidence interval: 1.03-5.04). Conclusion The open approach is increasingly utilized for only the most complex lesions, and selection bias cannot be overstated in comparative series. This study suggests that current open complication rates may be above those cited from prior studies, and patient and physician expectations should be adjusted accordingly.

Family presence and participation during medical visits of heart failure patients: An analysis of survey and audiotaped communication data.

OBJECTIVE: To describe the frequency, roles, and utility of family companion involvement in the care of patients with Heart Failure (HF) care and to examine the association between audiotaped patient, companion, and provider communication behaviors. METHODS: We collected survey data and audiotaped a single medical visit for 93 HF patients (36 brought a companion into the examination room) and their cardiology provider. Communication data was analyzed using the Roter Interaction Analysis System. RESULTS: There were 32% more positive rapport-building statements (p<0.01) and almost three times as many social rapport-building statements (p<0.01) from patients and companions in accompanied visits versus unaccompanied patient visits. There were less psychosocial information giving statements in accompanied visits compared to unaccompanied patient visits (p<0.01.) Providers made 25% more biomedical information giving statements (p=0.04) and almost three times more social rapport-building statements (p<0.01) in accompanied visits. Providers asked fewer biomedical and psychosocial questions in accompanied versus unaccompanied visits. Providers made 16% fewer partnership-building statements in accompanied versus unaccompanied visits (p=0.01). CONCLUSIONS: Our findings are mixed regarding the benefits of accompaniment for facilitating patient-provider communication based on survey and audiotaped data. PRACTICE IMPLICATIONS: Strategies to enhance engagement during visits, such as pre-visit question prompt lists, may be beneficial.

Family member accompaniment to routine medical visits is associated with better self-care in heart failure patients.

OBJECTIVES: To examine the association between frequency of family member accompaniment to medical visits and heart failure (HF) self-care maintenance and management and to determine whether associations are mediated through satisfaction with provider communication. METHODS: Cross-sectional survey of 150 HF patients seen in outpatient clinics. HF self-care maintenance and management were assessed using the Self-Care of Heart Failure Index. Satisfaction with provider communication was assessed using a single question originally included in the American Board of Internal Medicine Patient Satisfaction Questionnaire. Frequency of family member accompaniment to visits was assessed using a single-item question. We performed regression analyses to examine associations between frequency of accompaniment and outcomes. Mediation analysis was conducted using MacKinnon's criteria. RESULTS: Overall, 61% reported accompaniment by family members to some/most/every visit. Accompaniment to some/most/every visit was associated with higher self-care maintenance (ß = 6.4, SE 2.5; p = 0.01) and management (ß = 12.7, SE 4.9; p = 0.01) scores. Satisfaction with provider communication may mediate the association between greater frequency of accompaniment to visits and self-care maintenance (1.092; p = 0.06) and self-care management (1.428; p = 0.13). DISCUSSION: Accompaniment to medical visits is associated with better HF self-care maintenance and management, and this effect may be mediated through satisfaction with provider communication.

Completion of advance directives among U.S. consumers.

BACKGROUND: Current, ongoing national surveys do not include questions about end-of-life (EOL) issues. In particular, population-based data are lacking regarding the factors associated with advance directive completion. PURPOSE: To characterize U.S. adults who did and did not have an advance directive and examine factors associated with their completion, such as the presence of a chronic condition and regular source of health care. METHODS: Data were analyzed in 2013 from adults aged 18 years and older who participated in the 2009 or 2010 HealthStyles Survey, a mail panel survey designed to be representative of the U.S. population. Likelihood ratio tests were used to examine the associations between advance directive completion and demographic and socioeconomic variables (education, income, employment status); presence of a chronic condition; regular source of health care; and self-reported EOL concerns or discussions. Multiple logistic regression analyses identified independent predictors related to advance directive completion. RESULTS: Of the 7946 respondents, 26.3% had an advance directive. The most frequently reported reason for not having one was lack of awareness. Advance directive completion was associated with older age, more education, and higher income and was less frequent among non-white respondents. Respondents with advance directives also were more likely to report having a chronic disease and a regular source of care. Advance directives were less frequent among those who reported not knowing if they had an EOL concern. CONCLUSIONS: These data indicate racial and educational disparities in advance directive completion and highlight the need for education about their role in facilitating EOL decisions.

Clinical outcomes with rapid detection of methicillin-resistant and methicillin-susceptible Staphylococcus aureus isolates from routine blood cultures.

Staphylococcus aureus is a common cause of bacteremia, with a substantial impact on morbidity and mortality. Because of increasing rates of methicillin-resistant Staphylococcus aureus, vancomycin has become the standard empirical therapy. However, beta-lactam antibiotics remain the best treatment choice for methicillin-susceptible strains. Placing patients quickly on the optimal therapy is one goal of antimicrobial stewardship. This retrospective, observational, single-center study compared 33 control patients utilizing only traditional full-susceptibility methodology to 22 case patients utilizing rapid methodology with CHROMagar medium to detect and differentiate methicillin-resistant and methicillin-susceptible Staphylococcus aureus strains hours before full susceptibilities were reported. The time to targeted therapy was statistically significantly different between control patients (mean, 56.5 ± 13.6 h) and case patients (44.3 ± 17.9 h) (P = 0.006). Intensive care unit status, time of day results emerged, and patient age did not make a difference in time to targeted therapy, either singly or in combination. Neither length of stay (P = 0.61) nor survival (P = 1.0) was statistically significantly different. Rapid testing yielded a significant result, with a difference of 12.2 h to targeted therapy. However, there is still room for improvement, as the difference in time to susceptibility test result between the full traditional methodology and CHROMagar was even larger (26.5 h). This study supports the hypothesis that rapid testing plays a role in antimicrobial stewardship by getting patients on targeted therapy faster.

Causal discounting in the presence of a stronger cue is due to bias.

People use information about the covariation between a putative cause and an outcome to determine whether a causal relationship obtains. When there are two candidate causes and one is more strongly related to the effect than is the other, the influence of the second is underestimated. This phenomenon is called causal discounting. In two experiments, we adapted paradigms for studying causal learning in order to apply signal detection analysis to this phenomenon. We investigated whether the presence of a stronger alternative makes the task more difficult (indexed by differences in d') or whether people change the standard by which they assess causality (measured by beta). Our results indicate that the effect is due to bias.