Assessment of Determinants of Value in Carotid Endarterectomy.

BACKGROUND: Over 150,000 carotid endarterectomies (CEA) are performed annually worldwide, accounting for $900 million in the United States alone. How cost/spending and quality are related is not well understood but remain essential components in maximizing value. We sought to identify determinants of variability in hospital 90-day episode value for CEA. METHODS: Medicare and private-payer admissions for CEA from January 2, 2014 to August 28, 2020 were linked to retrospective clinical registry data for hospitals in Michigan performing vascular surgery. Hospital-specific, risk-adjusted, 30-day composite complications (defined as reoperation, new neurologic deficit, myocardial infarction, additional procedure including CEA or carotid artery stenting, readmission, or mortality) and 30-day risk-adjusted, price-standardized total episode payments were used to categorize hospitals into low or high value by defining the intersection between complications and spending. RESULTS: A total of 6,595 patients across 39 hospitals were identified across both datasets. Patients at low-value hospitals had a higher rate of 30-day composite complications (17.9% vs. 10.1%, P < 0.001) driven by a significantly higher rate of reoperation (3.0% vs. 1.4%, P = 0.016), readmission (10.7% vs. 6.2%, P = 0.012), new neurologic deficit (4.6% vs. 2.3%, P = 0.017), and mortality (1.6% vs. 0.6%, P < 0.049). Mean total episode payments were $19,635 at low-value hospitals compared to $15,709 at high-value hospitals driven by index hospitalization ($10,800 vs. $9,587, P = 0.002), professional ($3,421 vs. $2,827, P < 0.001), readmission ($3,011 vs. $1,826, P < 0.001), and post-acute care payments ($2,335 vs. $1,486, P < 0.001). Findings were similar when only including patients who did not suffer a complication. CONCLUSIONS: There is tremendous variation in both quality and payments across hospitals included for CEA. Importantly, costs were higher at low-value hospitals independent of postoperative complication. There appears to be little to no relationship between total episode spending and surgical quality, suggesting that improvements in value may be possible by decreasing total episode cost without affecting surgical outcomes.

Antibiotic Use in Patients With ß-Lactam Allergies and Pneumonia: Impact of an Antibiotic Side Chain-Based Cross-Reactivity Chart Combined With Enhanced Allergy Assessment.

BACKGROUND: ß-lactam antibiotics with dissimilar R-group side chains are associated with low cross-reactivity. Despite this, patients with ß-lactam allergies are often treated with non-ß-lactam alternative antibiotics. An institutional ß-lactam side chain-based cross-reactivity chart was developed and implemented to guide in antibiotic selection for patients with ß-lactam allergies. METHODS: This single-center, retrospective cohort study analyzed the impact of the implementation of the cross-reactivity chart for patients with pneumonia. Study time periods were defined as January 2013 to October 2014 prior to implementation of the chart (historical cohort) and January 2017 to October 2018 (intervention cohort) following implementation. The primary outcome was the incidence of ß-lactam utilization between time periods. Propensity-weighted scoring and interrupted time-series analyses compared outcomes. RESULTS: A total of 341 and 623 patient encounters were included in the historical and intervention cohorts, respectively. There was a significantly greater use of ß-lactams in the intervention cohort (70.4% vs 89.3%; P < .001) and decreased use of alternative therapy (58.1% vs 36%; P < .001). There was no difference in overall allergic reactions between cohorts (2.4% vs 1.6%; P = .738) or in reactions caused by ß-lactams (1.3% vs 0.9%; P = .703). Inpatient mortality increased (0% vs 6.4%; P < .001); however, no deaths were due to allergic reactions. Healthcare facility-onset Clostridioides difficile infections decreased between cohorts (1.2% vs 0.2%; P = .032). CONCLUSIONS: Implementation of a ß-lactam side chain-based cross-reactivity chart and enhanced allergy assessment was associated with increased use of ß-lactams in patients with pneumonia without increasing allergic reactions.

Physical Examination for the Detection of Pulmonary Hypertension: A Systematic Review.

We performed a systematic review to determine whether the physical examination can reliably assist in the diagnostic approach for patients suspected of having pulmonary hypertension (PH). Using dual extraction, two investigators independently searched PubMed, Ovid MEDLINE, Cochrane Library, and Embase for studies that compared physical examination findings with a right heart catheterization, from inception until July 10, 2021. We obtained data from four studies that evaluated physical examination findings in patients receiving a right heart catheterization to diagnose PH. Pooled diagnostic odds ratios (DOR) were calculated for right ventricular heave, a loud pulmonic component of the second heart sound (P2), jugular venous pressure (JVP) 3 cm above sternal angle, and a palpable P2. Three physical examination findings had DOR that supports the diagnosis of PH: the JVP > 3 cm above the sternal angle (5.90, 95% CI 2.57, 13.57), a loud P2 (2.91, 95% CI 1.38, 6.10), and a right ventricular heave (2.78, 95% CI 1.12, 6.89). The palpable P2 had a DOR less than one and was not able to be conclusive in diagnosing PH. Our systematic review found a small body of evidence supporting the use of physical examination tests in the diagnostic evaluation of pulmonary hypertension. The JVP > 3 cm above the sternal angle was the most accurate physical examination sign for the diagnosis of PH. Larger cohort studies using a combination of tests may shed more light on the role of the physical examination in the diagnosis and early detection of pulmonary hypertension.

Cancer Screening During the COVID-19 Pandemic: A Systematic Review and Meta-analysis.

The purpose of this study was to assess the impact of measures designed to mitigate the spread of coronavirus disease 2019 (COVID-19) on worldwide cancer screening. We systematically searched PubMed, Ovid MEDLINE, the Cochrane COVID-19 Study Register, ClinicalTrials.gov, and EMBASE without language restrictions for studies published between January 1, 2021, and February 10, 2021. Studies selected for full-text review contained data on patients screened for any type of cancer during the COVID-19 pandemic and comparison data from a time interval just prior to the pandemic. Data were obtained through dual extraction. All the included studies were assessed for quality and risk of bias. A meta-analysis was performed on 13 studies: 7 on screening mammography, 5 on colon cancer screening, and 3 on cervical cancer screening. Two of our studies reported on more than one type of cancer screening. The screening outcomes were reported as pooled incidence rate ratios using the inverse variance method and random effects models. All studies included in our meta-analysis reported the number of patients screened for cancer in defined time intervals before and during the COVID-19 pandemic. We found that the pooled incidence rate ratios were significantly lower for screening during the COVID-19 pandemic for breast cancer (0.63; 95% CI, 0.53 to 0.77; P<.001), colon cancer (0.11; 95% CI, 0.05 to 0.24; P<.001), and cervical cancer (0.10; 95% CI, 0.04 to 0.24; P<.001). These findings may add further morbidity and mortality to this public health crisis.

Effective Treatment of Nonalcoholic Fatty Liver Disease Using a Community-Based Weight Management Program.

Introduction Obesity-related gastrointestinal disorders including nonalcoholic fatty liver disease (NAFLD) and gastroesophageal reflux disease (GERD) are more frequent and usually present earlier than type 2 diabetes mellitus (T2DM) and cardiovascular disorders. This provides an opportunity for the gastroenterologist to intervene early with an effective weight-loss therapy. We evaluated the outcomes of a multifaceted, community-based gastroenterologist-supervised weight management program compared with patient-directed weight-loss efforts after physician advice. The program is aimed at achieving a 10% total body weight (TBW) loss at three months, a known determinant for NAFLD regression. Methods This is a retrospective pre- and post-intervention study of NAFLD patients, who participated in a medically supervised weight management program in the period between May 2017 and May 2019. The program is comprised of a very-low-calorie (800 kcal/day) meal replacement diet, a recommended medical fitness program, and weekly behavioral support groups. Patients are followed on monthly basis and slowly transitioned to a whole food plant-based or Mediterranean diet after three months of participation. Patients' weight trends driven by self-directed efforts to lose weight after physician advice were collected based on historical data up to two years prior to program participation. The primary outcome was defined as percentage TBW loss at three months under medical supervision (post-intervention) compared with patient-directed weight-loss efforts (pre-intervention). The secondary outcomes included percentage TBW loss in relation to behavioral support group attendance and improvement in GERD and T2DM disease status after program participation. Linear mixed and linear regression models were used to assess for a statistically significant difference in percentage TBW loss. Statistical significance was defined as p < 0.05. Results A total of 114 NAFLD patients (mean age 55 years, mean BMI 39 kg/m2, 77 females, and 37 males) completed at least three months of follow-up and were included in the study. Of those, 89 patients had a documented three-month office visit. At three months, 65% of patients had lost at least 10% of their TBW. Percentage TBW loss under medical supervision was noted to be significantly higher and occurred at a faster rate over three months when compared with patient-directed efforts after physician advice (p < 0.001). Patients who attended the behavioral support groups ≥ 50% of the time had a 3% higher TBW loss at three months compared with patients who attended <50% of the time (p = 0.006). Approximately, 52% of patients with GERD and 38% of patients with T2DM had symptoms improvement and/or medication reduction at their three-month follow-up visit. Conclusion A multifaceted, community-based, gastroenterologist supervised weight management program is effective in achieving a clinically significant TBW loss of at least 10% within three months of participation. This weight loss was greater and occurred at a faster rate when compared with patient-directed efforts. Additionally, improvement in GERD and T2DM disease status was noted in 52% and 38% of patients with these conditions, respectively. Further community-based studies of a larger scale are needed to determine the sustainability of this weight loss over one year.

Phenobarbital Versus Lorazepam for Management of Alcohol Withdrawal Syndrome: A Retrospective Cohort Study.

Introduction  Annually, 500,000 episodes of alcohol withdrawal syndrome (AWS) are severe enough to require clinical attention. A symptom-triggered lorazepam regimen remains the standard of care for the management of hospitalized AWS patients. However, phenobarbital has also been shown to be an effective adjunctive therapy for severe AWS, reducing benzodiazepine use in the emergency department (ED) and the intensive care unit (ICU). The purpose of this study is to compare hospital length of stay (LOS) for AWS patients using phenobarbital-based versus lorazepam-based treatment protocols as monotherapy for management of AWS on general medical units. Methods This is a retrospective cohort study over a two-year period (March, 2016 to March, 2018), conducted at three hospitals within the St. Joseph Mercy Health System. We included 606 patients with a primary diagnosis of AWS or alcohol intoxication who met our inclusion criteria (543 in the lorazepam cohort and 63 in the phenobarbital cohort). Adjusted comparisons were done using propensity scoring methods. Hospital LOS was set as the primary outcome. Secondary outcomes included all-cause 30-day readmission, alcohol-related 30-day readmission, 30-day ED visits after discharge, and need for ICU transfer during hospital stay. Results Patients who received phenobarbital had a statistically significant shorter hospital LOS as compared to patients who received lorazepam (2.8 versus 3.6 days, P < 0.001). Furthermore, the phenobarbital treatment group had statistically significant lower rates of all-cause 30-day readmission (11.11% versus 14.18%, P = 0.020) and 30-day ED visits after discharge (11.11% versus 18.6%, P = 0.015). No statistical significance was detected for alcohol-related 30-day readmission and the need for ICU transfer between the treatment groups. Conclusion This study suggests that phenobarbital may be a reasonable alternative to lorazepam in the management of AWS patients admitted to general medical units. Larger scale, well-executed, and adequately powered prospective studies and randomized controlled trials are needed to corroborate these findings.

Impact of a Mortality Prediction Rule for Organizing and Guiding Antimicrobial Stewardship Program Activities.

BACKGROUND: Antimicrobial stewardship program (ASP) surveillance at our hospital is supplemented by an internally developed surveillance database. In 2013, the database incorporated a validated, internally developed, prediction rule for patient mortality within 30 days of hospital admission. This study describes the impact of an expanded ASP review in patients at the highest risk for mortality. METHODS: This retrospective, quasi-experimental study analyzed adults who received antimicrobials with the highest mortality risk score. Study periods were defined as 2011-Q3 2013 (historical group) and Q4 2013-2018 (intervention group). Primary and secondary outcomes were assessed for confounders and analyzed using both unadjusted and propensity score weighted analyses. Interrupted time-series analyses also analyzed key outcomes. RESULTS: A total of 3282 and 5456 patients were included in the historical and intervention groups, respectively. There were significant reductions in median antimicrobial duration (5 vs 4 days; P < .001), antimicrobial days of therapy (8 vs 7; P < .001), antimicrobial cost ($96 vs $85; P = .003), length of stay (LOS) (6 vs 5 days; P < .001), intensive care unit (ICU) LOS (3 vs 2 days; P < .001), total hospital cost ($10 946 vs $9119; P < .001), healthcare facility-onset vancomycin-resistant Enterococcus (HO-VRE) incidence (1.3% vs 0.3%; P ≤ .001), and HO-VRE infections (0.6% vs 0.2%; P = .018) in the intervention cohort. CONCLUSIONS: Reductions in antimicrobial use, hospital and ICU LOS, HO-VRE, HO-VRE infections, and costs were associated with incorporation of a novel mortality prediction rule to guide ASP surveillance and intervention.

The Utility of Rapid Nucleic Acid Amplification Testing to Triage Symptomatic Patients and to Screen Asymptomatic Preprocedure Patients for SARS-CoV-2.

We investigate the utility of the ID Now when compared to RT-PCR to triage patients suspected of having COVID-19 presenting to emergency rooms (ERs) and to screen asymptomatic patients presenting for pre-procedural testing. We find it useful when prevalence of COVID-19 is high in symptomatic patents and potentially useful in asymptomatic patients who are likely to be retested if symptoms emerge.

Impact of an Antibiotic Side-Chain-Based Cross-reactivity Chart Combined With Enhanced Allergy Assessment Processes for Surgical Prophylaxis Antimicrobials in Patients With ß-Lactam Allergies.

BACKGROUND: ß-Lactam antibiotics are first-line therapy for perioperative prophylaxis; however, patient-reported allergies often lead to increased prescribing of alternative antibiotics that may increase the incidence of surgical site infections. The R-group side chain of the ß-lactam ring is responsible for allergic cross-reactivity and experts recommend the use of ß-lactams that are structurally dissimilar. METHODS: An internally developed, antibiotic side-chain-based cross-reactivity chart was developed and implemented alongside enhanced allergy assessment processes. This single-center, quasi-experimental study analyzed antibiotic prescribing in all adult patients with a documented ß-lactam allergy undergoing an inpatient surgical procedure between quartile (Q) 1 (2012)-Q3 (2014) (historical group) and Q3 (2016)-Q3 (2018) (intervention group). Propensity-weighted scoring analyses compared categorical and continuous outcomes. Interrupted time-series analysis further analyzed key outcomes. RESULTS: A total of 1119 and 1089 patients were included in the historical and intervention cohorts, respectively. There was a significant difference in patients receiving a ß-lactam alternative antibiotic between cohorts (84.9% vs 15.1%; P < .001). There was a decrease in 30-day readmissions in the intervention cohort (7.9% vs 6.3%; P = .035); however, there was no difference in the incidence of SSIs in patients readmitted (14.8% vs 13%; P = .765). No significant differences were observed in allergic reactions (0.5% vs 0.3%; P = .323), surgical site infections, in-hospital and 30-day mortality, healthcare facility-onset Clostridiodes difficile infection, acute kidney injury, or hospital costs. CONCLUSIONS: Implementation of an antibiotic cross-reactivity chart combined with enhanced allergy assessment processes significantly improved the prescribing of ß-lactam antibiotics for surgical prophylaxis.

Impact of Biopsy Technique on Clinically Important Outcomes for Cutaneous Melanoma: A Systematic Review and Meta-analysis.

We performed a systematic review and meta-analysis to examine the relationship between the type of biopsy technique employed in the diagnosis of cutaneous melanoma and 4 clinically important outcomes: melanoma-specific mortality, all-cause mortality, Breslow tumor depth, or melanoma recurrence. Our database was obtained by searching PubMed, Ovid MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Library from inception until December 6, 2019. Studies were identified that compared biopsy techniques used to diagnose cutaneous melanoma with any of our study outcomes. We included 7 observational studies for our meta-analysis after screening 3231 titles and abstracts. Pooled data identified a significantly higher all-cause mortality in the punch biopsy group (risk ratio [RR], 1.520; P=.02). A higher, but nonsignificant, rate of melanoma-specific mortality (RR, 1.96; P=.22) and melanoma recurrence (RR, 1.20; P=.186) was also found for the punch biopsy group. Breslow tumor thickness was not significantly lower for punch incision (standardized mean difference, -0.42; P=.27). We found limited evidence for differences in clinically important outcomes across the spectrum of the most common methods employed in clinical practice for the initial diagnosis of cutaneous melanoma. A small, but significant, increase (P=.02) in all-cause mortality with punch biopsies was not seen for the other outcomes and was most likely due to small sample sizes and demographic differences in the included studies and unlikely represents a clinically important outcome. Our findings support the use of existing clinical practice guidelines for evaluating pigmented lesions suspicious for cutaneous melanoma.

Heart failure mortality prediction using PRISM score and development of a classification and regression tree model to refer patients for palliative care consultation.

INTRODUCTION: We sought to assess one-year mortality in heart failure (HF) patients by using (Placement Resource Indicator for Systems Management) PRISM, a disease nonspecific risk stratification score, and use it along with modified Seattle Heart Failure Model (SHFM) to guide patient selection for palliative care consultation. METHODS: A retrospective study design was used to examine 1-year mortality in 689 HF patients admitted from 2012 to 2014. One-year mortality was calculated using Pmort30/PRISM and modified SHFM scores, and the predicted scores were validated using the area under the ROC curve. CART was used to develop an algorithm to classify patients based on their mortality risk. RESULTS: The discriminatory ability of PRISM categorical score (AUC = 0.701) was not significantly different than the discriminatory ability of modified SHFM (AUC = 0.686) (DeLong's test p = 0.56) but improved significantly with the combination of PRISM (categorical) score + modified SHFM (AUC = 0.740) (p = 0.002). The predictive capability of the CART tree model after cross-validation was 72.2% (AUC 0.631). CONCLUSION: Our study suggests PRISM score performed as well as modified SHFM for one-year mortality prediction. Moreover, the addition of modified SHFM to PRISM score increases discriminatory ability in predicting 1-year mortality in heart failure patients compared to either of the two models alone. Together, when combined in a CART model, they can be used to identify the population subset with the highest mortality risk and hence guide goals of care discussion.

Do Common Marmosets (Callithrix jacchus) Use Scent to Communicate Information about Food Resources?

Many animals use olfactory cues to signal information about food resources; however, this particular use of scent has received little attention in primates. Common marmosets (Callithrix jacchus) are exudativores that gouge bark to elicit exudate production and frequently deposit scent marks at gouge holes. We conducted preliminary tests of the hypothesis that common marmosets use olfactory cues to communicate information about exudate value, with more desirable resources targeted for marking. We performed choice experiments on two captive male marmosets. The animals were presented with: (1) a urine scent-marked and unmarked food resource, and (2) a high and low value food resource (i.e., greater/lesser food volumes). Marmosets placed more scent marks on high, compared to low, value food resources. Animals also spent more time gouging, removed more bark and more frequently revisited high versus low value food resources. Lastly, scent-marked foods were gouged more often than unmarked foods. Our findings support the hypothesis that marmosets use scent marking and olfaction to convey information about food resources, although verification in a larger sample is needed. Nonetheless, the demonstrated link between food value and scent marking suggests that olfactory signals may aid marmoset foraging decisions.

An assessment of skin temperature gradients in a tropical primate using infrared thermography and subcutaneous implants.

Infrared thermography has become a useful tool to assess surface temperatures of animals for thermoregulatory research. However, surface temperatures are an endpoint along the body's core-shell temperature gradient. Skin and fur are the peripheral tissues most exposed to ambient thermal conditions and are known to serve as thermosensors that initiate thermoregulatory responses. Yet relatively little is known about how surface temperatures of wild mammals measured by infrared thermography relate to subcutaneous temperatures. Moreover, this relationship may differ with the degree that fur covers the body. To assess the relationship between temperatures and temperature gradients in peripheral tissues between furred and bare areas, we collected data from wild mantled howling monkeys (Alouatta palliata) in Costa Rica. We used infrared thermography to measure surface temperatures of the furred dorsum and bare facial areas of the body, recorded concurrent subcutaneous temperatures in the dorsum, and measured ambient thermal conditions via a weather station. Temperature gradients through cutaneous tissues (subcutaneous-surface temperature) and surface temperature gradients (surface-ambient temperature) were calculated. Our results indicate that there are differences in temperatures and temperature gradients in furred versus bare areas of mantled howlers. Under natural thermal conditions experienced by wild animals, the bare facial areas were warmer than temperatures in the furred dorsum, and cutaneous temperature gradients in the face were more variable than the dorsum, consistent with these bare areas acting as thermal windows. Cutaneous temperature gradients in the dorsum were more closely linked to subcutaneous temperatures, while facial temperature gradients were more heavily influenced by ambient conditions. These findings indicate that despite the insulative properties of fur, for mantled howling monkeys surface temperatures of furred areas still demonstrate a relationship with subcutaneous temperatures. Given that most mammals possess dense fur, this provides insight for using infrared imaging in thermoregulatory studies of wild animals lacking bare skin.