Increasing Trainee Comfort with Nutrition.

OBJECTIVES: Nutrition counseling is necessary for the prevention and treatment of many chronic diseases. US survey data demonstrate that 61% of Internal Medicine (IM) residents receive little to no nutrition training. The objective of our study was to develop a curriculum to increase IM resident comfort and ability in conducting a nutritional assessment. METHODS: Categorical IM residents at a large academic medical center participated in a curriculum that included a lecture, a small-group discussion, and a skills exercise. Residents completed pre- and posttest surveys that evaluated their attitudes and comfort level with nutritional assessment. RESULTS: Eighty percent (84/105) of the residents participated in the curriculum and 48% (40/84) of them completed both pre- and postsession surveys. Residents who considered themselves moderately to extremely comfortable completing a nutritional assessment increased after the program (27.5% to 87.5%, P < 0.0001). The proportion of those who agreed or strongly agreed with the statement, "Nutritional counseling should be included in any routine appointment, just like diagnosis and treatment," increased from 62.50% to 80.00% (P = 0.012). The proportion of residents who considered lack of individual knowledge to be a barrier for nutrition counseling decreased from 65.79% to 42.11% (P = 0.0126). CONCLUSIONS: This curriculum was successful in increasing IM resident comfort with conducting a nutritional assessment.

Thick Liquids and Clinical Outcomes in Hospitalized Patients With Alzheimer Disease and Related Dementias and Dysphagia.

Importance: Oropharyngeal dysphagia is common in hospitalized patients with Alzheimer disease and related dementias (ADRD). Although the use of thick liquids in patients with dysphagia has been shown to reduce aspiration on direct visualization, there is no clear evidence that this practice translates into improved clinical outcomes. Objectives: To determine whether a diet of thick liquids compared with thin liquids is associated with improved outcomes in hospitalized patients with ADRD and dysphagia. Design, Setting, and Participants: This cohort study included adults aged 65 years and older with ADRD who were admitted to the medicine service across 11 diverse hospitals in New York between January 1, 2017, and September 20, 2022, with clinical suspicion of dysphagia during hospitalization and survival for at least 24 hours after hospital arrival. Patients were grouped according to whether at least 75% of their hospital diet consisted of a thick liquid diet or a thin liquid diet. Propensity score matching was used to balance covariates across the 2 groups for the following covariates: demographics (eg, age, sex), baseline clinical characteristics (eg, Charlson Comorbidity Index), and acute presentation (eg, respiratory diagnosis, illness severity, delirium). Main Outcomes and Measures: Hospital outcomes included mortality (primary outcome), respiratory complications (eg, pneumonia), intubation, and hospital length of stay (LOS). Results: Of 8916 patients with ADRD and dysphagia included in the propensity score matched analysis, the mean (SD) age was 85.7 (8.0) years and 4829 were female (54.2%). A total of 4458 patients receiving a thick liquid diet were matched with 4458 patients receiving a thin liquid diet. There was no significant difference in hospital mortality between the thick liquids and thin liquids groups (hazard ratio, 0.92; 95% CI, 0.75-1.14]; P = .46). Compared with patients receiving thin liquids, patients receiving thick liquids were less likely to be intubated (odds ratio [OR], 0.66; 95% CI, 0.54-0.80), but they were more likely to have respiratory complications (OR, 1.73; 95% CI, 1.56-1.91). Conclusions and Relevance: This cohort study emphasizes the need for prospective studies that evaluate whether thick liquids are associated with improved clinical outcomes in hospitalized patients with ADRD and dysphagia.

Differences in Glycemic Control for Inpatients with Type 1 Diabetes on Insulin Pump Versus Subcutaneous Insulin Therapy.

BACKGROUND: Inpatient use of insulin pump therapy has been increasing due to greater availability of this technology, however there is a paucity of research that investigates glycemic control of inpatient insulin pump users. OBJECTIVE: To compare the glycemic control of hospitalized patients with type 1 diabetes (T1D) who used insulin pump vs. multiple daily injections (MDI). DESIGN: Retrospective chart review. PARTICIPANTS: Patients with T1D who were hospitalized between January 1, 2017, and December 31, 2019, in an academic medical center in the New York metropolitan area. MAIN MEASURES: Patients were categorized into three groups based on their method of insulin administration: "pump only" group used insulin pump exclusively, "MDI only" group used MDI only, and "intermittent pump" group used a combination of both methods. The primary endpoints are mean blood glucose, rates of hypoglycemic events (blood glucose < 70 mg/dL), and rates of hyperglycemic events (blood glucose > 250 mg/dL). Separate multivariable Poisson regressions were performed to determine the association between the type of insulin administration and rate outcomes (i.e., rate of hypoglycemic events and rate of hyperglycemic events). RESULTS: The study included 78 patients with a mean age of 51, who were mostly male (54%), and white (72%). The average proportion of glucose measurements that were hyperglycemic for the "pump only", "MDI only", and "intermittent pump" groups were 0.11 (SD = 0.11), 0.25 (SD = 0.19), and 0.24 (SD = 0.25), respectively. The "pump only" group has a significantly lower proportion of hyperglycemic events as compared to the "MDI only" group (p = 0.0227). CONCLUSIONS: In this sample, patients who exclusively used their insulin pump while inpatient had a lower rate of hyperglycemic events than patients who used MDI only; suggesting that select patients can safely continue their insulin pump therapy in the inpatient setting.

Demographic Variables Associated With Diabetes Technology Awareness or Use in Adults With Type 2 Diabetes.

Background: Studies in populations with type 1 diabetes highlight racial/ethnic disparities in the use of diabetes technology; however, little is known about disparities among those with type 2 diabetes. This project investigates the racial/ethnic and socioeconomic disparities in diabetes technology awareness and use in adults with type 2 diabetes in the ambulatory setting. Methods: Adults ≥40 years of age with type 2 diabetes in ambulatory care were invited to participate via an e-mail link to a de-identified REDCap (Research Electronic Data Capture) questionnaire. Variables, including awareness and use of continuous glucose monitoring (CGM) and insulin pumps, were summarized descriptively using frequencies and percentages and were compared across racial/ethnic groups, education level, and income using Pearson χ2 or Fisher exact tests. Results: The study included 116 participants, most of whom (62%) were White, elderly Medicare recipients. Compared with White participants, those of racially/ethnically minoritized groups were less likely to be aware of CGM (P = 0.013) or insulin pumps (P = 0.001). Participants with a high school education or less were also less likely to be aware of insulin pumps (P = 0.041). Interestingly, neither awareness nor use of CGM or insulin pumps was found to be associated with income. Conclusion: This cross-sectional analysis suggests that racially/ethnically minoritized groups and individuals with lower education have less awareness of CGM or insulin pumps.

Cannabis Use and Its Association With Thirty- and Ninety-Day Hospital Readmissions for Patients Admitted for an Inflammatory Bowel Disease Exacerbation.

Background: Though viewed as a potentially safer palliative alternative to opioids, studies of cannabis use for inflammatory bowel disease (IBD) are limited. The impact of opioids on hospital readmissions for IBD has been extensively examined, but cannabis has not been similarly studied. Our goal was to examine the relationship between cannabis use and the risk of 30- and 90-day hospital readmissions. Methods: We conducted a review of all adults admitted for an IBD exacerbation from January 1, 2016 to March 1, 2020 within the Northwell Health Care system. Patients with an IBD exacerbation were identified by primary or secondary ICD10 code (K50.xx or K51.xx) and administration of intravenous (IV) solumedrol and/or biologic therapy. Admission documents were reviewed for the terms "marijuana", "cannabis", "pot" and "CBD". Results: A total of 1,021 patient admissions met inclusion criteria, of whom 484 (47.40%) had Crohn's disease (CD) and 542 (53.09%) were female. Pre-admission cannabis use was reported by 74 (7.25%) patients. Factors found to be associated with cannabis use included younger age, male gender, African American/Black race, current tobacco and former alcohol use, anxiety, and depression. Cannabis use was found to be associated with 30-day readmission among patients with ulcerative colitis (UC), but not among patients with CD, after respectively adjusting each final model by other factors (odds ratio (OR): 2.48, 95% confidence interval (CI): 1.06 - 5.79 and OR: 0.59, 95% CI: 0.22 - 1.62, respectively). Cannabis use was not found to be associated with 90-day readmission on univariable analysis (OR: 1.11, 95% CI: 0.65 - 1.87) nor in the final multivariable model after adjusting for other factors (OR: 1.19, 95% CI: 0.68 - 2.05). Conclusion: Pre-admission cannabis use was found to be associated with 30-day readmission among patients with UC, but not with 30-day readmission for patients with CD nor with 90-day readmission, following an IBD exacerbation.

A comparison of magnetic resonance elastography (MRE) to biomarker testing for staging fibrosis in non-alcoholic fatty liver disease (NAFLD).

Background: Non-alcoholic fatty liver disease (NAFLD) is the world's most prevalent chronic liver disease. In advanced stages, it is associated with significant morbidity and mortality. Magnetic resonance elastography (MRE) and scoring panels Fibrosis-4 (FIB-4) and NAFLD Fibrosis Score (NFS) are useful noninvasive alternatives to liver biopsy for fibrosis staging. Our study aimed to determine how well MRE corresponds with both FIB-4 and NFS at different stages of fibrosis. Methods: We performed a retrospective chart review of patients age ≥18 with NAFLD as their only known liver disease who underwent MRE within six months of a lab draw. MRE stratified patients into fibrosis stages using kPa values. FIB-4 categorized patients as Advanced Fibrosis Excluded, Further Investigation Needed or Advanced Fibrosis Likely. NFS categorized them as F0-2, Indeterminate or F3-4. MRE fibrosis staging was compared to FIB-4 and NFS for both ruling out advanced fibrosis and identifying advanced fibrosis/cirrhosis. Results: Overall, 193 patients met inclusion criteria. Our statistical analysis included calculating positive predictive values (PPVs) and negative predictive values (NPVs), which are the proportions of positive and negative fibrosis screening results that correspond to positive and negative MRE results respectively. NPV for FIB-4 (0.84) and NFS (0.89) in the 'rule out advanced fibrosis' category signify that 84% and 89% of respective biomarker scores correspond to MRE in early stage disease. The PPV for FIB-4 and NFS in the 'identify advanced fibrosis/cirrhosis' category signify 63% and 72% of respective biomarker scores correspond to MRE in late stage disease. Conclusions: FIB-4 and NFS scores indicating little to no fibrosis correspond extremely well with MRE, while scores suggesting advanced fibrosis/cirrhosis correspond less convincingly. MRE shows promise as an effective alternative to liver biopsy, however our study suggests FIB-4 and NFS alone may be sufficient for fibrosis staging, particularly in early stage NAFLD.

A Retrospective Study Analyzing a Palliative Care-Hospital Medicine Collaboration to Improve Quality of Care of Patients With Advanced Illness.

BACKGROUND: Palliative care seeks to improve outcomes for patients with advanced illness (AI). Advocacy exists for making it part of mainstream care for hospitalized patients with AI. AIM: To determine if a partnership between hospital-medicine and specialized palliative care would increase identification of AI patients with palliative care needs requiring palliative consultation. Secondary outcomes: Decreasing 30-day readmission, length of stay (LOS) and pain scores, increasing documentation reflecting goals and advanced care planning. DESIGN: Retrospective chart review of patients with AI admitted to a hospitalist-resident run unit divided into Care Models, "A" and "B," and analyzed over two ten-month periods, "1" and "2." Triggers for palliative needs were provided for "A." During biweekly rounding, needs were assessed and generalist vs. specialist level palliative care concepts were used for consultation. SETTING: Quaternary-level teaching center in the New York Metropolitan area. PATIENTS: 3,395 AI patients were analyzed, 1,707 from "1," and 1,688 from "2." RESULTS: Comparing care models and time frames, palliative care consultation increased in "A" (P-value = .0013, P-value = .0005). When investigating "A" in "1" to "2," CMI was higher. Comparing "B" between "1" and "2," found older age and lower LACE. When adjusting for confounders (LACE and CMI), our models did not show a difference. Data on discharge disposition was significant for subacute rehab but not for mortality. There were no differences between care models and time-periods for secondary outcomes. CONCLUSION: Our study demonstrated the demand for palliative care services integrated into hospital medicine and highlighted areas of focus for future studies.

Randomized Open Investigation Determining Steroid Dose in Severe COVID-19: The ROIDS-Dose Clinical Trial.

Introduction Treatment with dexamethasone reduces mortality in patients with coronavirus disease 2019 (COVID-19) pneumonia requiring supplemental oxygen, but the optimal dose has not been determined. Objective To determine whether weight-based dexamethasone of 0.2 mg/kg is superior to 6 mg daily in reducing 28-day mortality in patients with COVID-19 and hypoxemia. Materials and methods A multicenter, open-label, randomized clinical trial was conducted between March 2021 and December 2021 at seven hospitals within Northwell Health. A total of 142 patients with confirmed COVID-19 and hypoxemia were included. Participants were randomized in a 1:1 ratio to dexamethasone 0.2 mg/kg intravenously daily (n = 70) or 6 mg daily (n = 72) for up to 10 days. Results There was no statistically significant difference in the primary outcome of 28-day all-cause mortality with deaths in 12 of 70 patients (17.14%) in the intervention group and 15 of 72 patients (20.83%) in the control group (p = 0.58). There were no statistically significant differences among the secondary outcomes. Conclusion In patients with COVID-19 and hypoxemia, the use of weight-based dexamethasone dosing was not superior to dexamethasone 6 mg in reducing all-cause mortality at 28 days. Clinical trial registration This study was registered under ClinicalTrials.gov (identifier: NCT04834375).

Adjuvant crizotinib in high-risk uveal melanoma following definitive therapy.

Introduction: Approximately 40% of patients with uveal melanoma (UM) will develop metastatic disease. Tumors measuring at least 12mm in basal diameter with a class 2 signature, as defined by a widely used gene expression-profiling test, are associated with significantly higher risk of metastasis, with a median time to recurrence of 32 months. No therapy has been shown to reduce this risk. Materials and Methods: This was a single-arm, multicenter study in patients with high-risk UM who received definitive treatment of primary disease and had no evidence of metastasis. Patients were consecutively enrolled to receive 12 four-week cycles of adjuvant crizotinib at a starting dose of 250mg twice daily and were subsequently monitored for 36 months. The primary outcome of this study was to assess recurrence-free survival (RFS) of patients with high-risk UM who received adjuvant crizotinib. Results: 34 patients enrolled and received at least one dose of crizotinib. Two patients were unevaluable due to early withdrawal and loss to follow-up, leaving 32 patients evaluable for efficacy. Eight patients (25%) did not complete the planned 48-week course of treatment due to disease recurrence (n=5) or toxicity (n=3). All patients experienced at least one adverse event (AE), with 11/34 (32%) experiencing a Common Terminology Criteria for Adverse Events (CTCAE) grade 3 or 4 AE. After a median duration of follow up of 47.1 months, 21 patients developed distant recurrent disease. The median RFS was 34.9 months (95% CI (Confidence Interval), 23-55 months), with a 32-month recurrence rate of 50% (95% CI, 33-67%). Analysis of protein contents from peripheral blood extracellular vesicles in a subset of patient samples from baseline, on-treatment, and off-treatment, revealed a change in protein content associated with crizotinib exposure, however without a clear association with disease outcome. Conclusions: The use of adjuvant crizotinib in patients with high-risk UM did not result in improved RFS when compared to historical controls. Analysis of blood extracellular vesicles revealed changes in protein content associated with treatment, raising the possibility of future use as a biomarker. Further investigation of adjuvant treatment options are necessary for this challenging disease.

Outcomes of kidney transplantation in patients with myeloma and amyloidosis in the USA.

BACKGROUND: Recent improvement in treatment and patient survival has opened the eligibility of kidney transplantation to patients who developed end-stage kidney disease (ESKD) from plasma cell dyscrasias (PCDs). Data on clinical outcomes in this population are lacking. METHODS: We conducted a retrospective study of United Network for Organ Sharing/Organ Procurement and Transplantation Network dataset (2006-2018) to compare patient and graft outcomes of kidney transplant recipients with ESKD due to PCD versus other causes. RESULTS: Among 168 369 adult first kidney transplant recipients, 0.22-0.43% per year had PCD as the cause of ESKD. The PCD group had worse survival than the non-PCD group for both living and deceased donor types {adjusted hazard ratio [aHR] 2.24 [95% confidence interval (CI) 1.67-2.99] and aHR 1.40 [95% CI 1.08-1.83], respectively}. The PCD group had worse survival than the diabetes group, but only among living donors [aHR 1.87 (95% CI 1.37-2.53) versus aHR 1.16 (95% CI 0.89-1.2)]. Graft survival in patients with PCD were worse than non-PCD in both living and deceased donors [aHR 1.72 (95% CI 1.91-2.56) and aHR 1.30 (95% CI 1.03-1.66)]. Patient and graft survival were worse in amyloidosis but not statistically different in multiple myeloma compared with the non-PCD group. CONCLUSION: The study data are crucial when determining kidney transplant eligibility and when discussing transplant risks in patients with PCD.

Auditing Management of Acute Pancreatitis Using Comprehensive Quality Indicators.

OBJECTIVES: Recently, 40 comprehensive quality indicators in various management domains were created. The aim was to determine if these indicators could be used to audit the management of acute pancreatitis. METHODS: A retrospective study of consecutive patients admitted with acute pancreatitis in 2018 was conducted. Adherence rates with the individual quality indicators were calculated and compared between services. RESULTS: A total of 320 patients were included in this study. Twenty-eight of the 40 quality indicators (70%) could be used to audit management retrospectively. The medical service was found to have lower adherence rates for quality indicators 12 (initial assessment and risk stratification domain; 11% vs 22%, P = 0.009), 14 (initial management domain; 72% vs 88%, P = 0.003), and 33 (surgery domain; 83% vs 100%, P = 0.006). The surgical service was noted to have statistically significant lower adherence rates for quality indicators 4, 5, and 6 of the etiology domain (54% vs 72%, P = 0.002; 86% vs 96%, P = 0.004; and 45% vs 71%, P < 0.0001, respectively), and 21 of the nutrition domain (76% vs 93%, P < 0.0001). CONCLUSIONS: We show that these quality indicators can be used to audit the management of acute pancreatitis in specific management domains.

Respiratory Distress in Hospitalized Non-Mechanically Ventilated COVID-19 Adults: A Retrospective Multicenter Cohort Study.

BACKGROUND: COVID-19 typically presents with respiratory symptoms which may progress with severe disease. There are standard guidelines for managing respiratory distress (e.g. opioids, anxiolytics) and palliative care teams are well versed in managing these symptoms. AIM: Determine the extent to which hospitalized COVID-19 patients with moderate respiratory distress received medications or palliative consultation for symptom management and if these interventions had any association with outcomes. DESIGN: Retrospective chart review for hospitalized COVID-19+ patients from March 2-April 30, 2020. SETTING: Large integrated health system in the New York Metropolitan area. PATIENTS: 312 adult patients hospitalized with COVID-19 with an order for a non-rebreather mask and meeting criteria for moderate respiratory distress on the Respiratory Distress Observation Scale: concurrent respiratory rate ≥30 and heart rate ≥110 at any point during hospitalization. Patients receiving mechanical ventilation or intensive care were excluded. RESULTS: Most COVID-19 patients experiencing moderate respiratory distress did not receive medications or palliative consultation for symptom management. Patients who received medications were predominantly white, older, and had a Do-Not-Resuscitate order. Patients who received a palliative consultation were more likely to be older, female, and white, with a Do-Not-Resuscitate order. Mortality was similar between those receiving medication and those who did not. CONCLUSION: Medications and palliative expertise for symptom management were underused for patients with moderate respiratory distress due to COVID-19. Education and triggers may help providers to identify moderate respiratory distress and consider symptomatic treatment and palliative consultation when appropriate.

Examination of anticoagulation prescription among elderly patients with atrial fibrillation after in-hospital fall.

Mechanical fall is common among elders and has been associated with a lack of anticoagulant therapy among patients with atrial fibrillation (AF). However, anticoagulant therapy is recommended despite frequent fall due to an increased risk of a thromboembolic event. Using data from a large health system, we investigated the predictors of anticoagulation prescription on discharge in AF elderly patients after an in-hospital fall. In this retrospective analysis, we examined patients aged 60 years and older discharged from 2013 to 2018 with a diagnosis of AF and a secondary diagnosis of in-hospital fall. The primary outcome was the prescription of anticoagulation at discharge. We obtained patients' demographical (race, sex, and health insurance status) and clinical (management by a resident team, receipt of a head CT or a cardiology consultation, ambulation status and discharge location) data. We further categorized the type of anticoagulation prescribed as warfarin or novel oral anticoagulants (NOACs). We ran chi-square and Fischer's exact tests on all data and multivariable logistic regressions on those of patients with pre-existing AF to identify the predictors of anticoagulation prescription on discharge. In total, 67% of 235 patients were discharged on anticoagulation. Of patients admitted on anticoagulation, 91% were prescribed anticoagulation on discharge (p < 0.001), while only 40% of patients with new-onset AF were discharged on anticoagulation (p < 0.001). Patients over the age of 90, compared to those aged 60-89, with existing AF had lower odds (OR = 0.34 [95% CI 0.12-0.98]) of being prescribed anticoagulation on discharge. Among patients with preexisting AF, being admitted on anticoagulation increased the odds (OR = 39.8 [15.2-104.0]) of anticoagulation prescription on discharge. Asian patients with prior AF were less likely (OR = 0.12 [0.026-0.060]) to receive anticoagulation on discharge. Of patients with new AF, 81% were prescribed a NOAC as opposed to warfarin (p < 0.05). These results suggest that provider's decisions on anticoagulation initiation seem to be guided more by their concerns over bleeding complications than by the patient's risk for stroke. However, anchoring bias strongly influences anticoagulation prescription. It may benefit AF patients already on anticoagulation, but it may prevent anticoagulation prescription in patients with new AF and Asian patients.

Laboratory and Pharmaceutical Data Associated With Hospital Readmission in Persons With Diabetic Foot Ulcers.

Purpose: Diabetic foot ulcers (DFUs) are a leading cause of lower extremity amputations among persons with diabetes (PWD) and a common cause of hospitalizations. This study identified demographic characteristics, lab values, and comorbidities associated with 30-day and 90-day hospital readmission in persons with DFU.Methods: A retrospective chart review at our institution examined 397 patients with type 2 diabetes admitted with DFU between January 2014 and December 2018. Variables were analyzed using descriptive statistics, t-tests, and logistic regressions.Results: None of the studied demographic, laboratory (including Hemoglobin A1c) or comorbid diseases were associated with 30-day readmission in persons with DFU. Risk factors for 90-day readmission included discharge location to home with health care (OR: 2.62, 95% CI: 1.39, 4.95), anticoagulant use (OR: 2.36, 95% CI: 1.27, 4.39), and SQ insulin use (OR: 2.08, 95% CI: 1.20, 3.61).Conclusions: None of the variables examined were associated with 30-day readmission; however, potential predictors for 90-day readmission included anticoagulation or insulin use and discharge home with healthcare services. Future studies should devise interventions to improve transition of care in patients with DFU to further assess the role of medications and home health care as a potential predictor of 90-day hospital readmission.

Hospital-Acquired Bloodstream Infections in Patients Hospitalized With Severe Acute Respiratory Syndrome Coronavirus 2 Infection (Coronavirus Disease 2019): Association With Immunosuppressive Therapies.

BACKGROUND: Immunosuppressive therapies proposed for Coronavirus disease 2019 (COVID-19) management may predispose to secondary infections. We evaluated the association of immunosuppressive therapies with bloodstream-infections (BSIs) in hospitalized COVID-19 patients. METHODS: This was an institutional review board-approved retrospective, multicenter, cohort study of adults hospitalized with COVID-19 over a 5-month period. We obtained clinical, microbiologic and laboratory data from electronic medical records. Propensity-score-matching helped create balanced exposure groups. Demographic characteristics were compared across outcome groups (BSI/no BSI) using two-sample t-test and Chi-Square test for continuous and categorical variables respectively, while immunosuppressive therapy use was compared using McNemar's test. Conditional logistic regression helped assess the association between immunosuppressive therapies and BSIs. RESULTS: 13,007 patients were originally included, with propensity-score-matching producing a sample of 6,520 patients. 3.74% and 3.97% were diagnosed with clinically significant BSIs in the original and propensity-score-matched populations respectively. COVID-19 patients with BSIs had significantly longer hospitalizations, higher intensive care unit admission and mortality rates compared to those without BSIs. On univariable analysis, combinations of corticosteroids/anakinra [odds-ratio (OR) 2.00, 95% confidence intervals (C.I.) 1.05-3.80, P value.0342] and corticosteroids/tocilizumab [OR 2.13, 95% C.I. 1.16-3.94, P value .0155] were significantly associated with BSIs. On multivariable analysis (adjusting for confounders), combination corticosteroids/tocilizumab were significantly associated with any BSI [OR 1.97, 95% C.I. 1.04-3.73, P value.0386] and with bacterial BSIs [OR 2.13, 95% C.I. 1.12-4.05, p-value 0.0217]. CONCLUSIONS: Combination immunosuppressive therapies were significantly associated with BSI occurrence in COVID-19 patients; their use warrants increased BSI surveillance. Further studies are needed to establish their causative role.

Evaluation of post-ERCP pancreatitis after biliary stenting with self-expandable metal stents vs. plastic stents in benign and malignant obstructions.

Background and study aims There are conflicting data regarding the risk of post-ERCP pancreatitis (PEP) with self-expandable metallic stents (SEMS) compared to polyethylene stents (PS) in malignant biliary obstructions and limited data related to benign obstructions. Patients and methods A retrospective cohort study was performed of 1136 patients who underwent ERCP for biliary obstruction and received SEMS or PS at a tertiary-care medical center between January 2011 and October 2016. We evaluated the association between stent type (SEMS vs PS) and PEP in malignant and benign biliary obstructions. Results Among the 1136 patients included in our study, 399 had SEMS placed and 737 had PS placed. Patients with PS were more likely to have pancreatic duct cannulation, pancreatic duct stent placement, double guidewire technique, sphincterotomy and sphincteroplasty as compared to the SEMS group. On multivariate analysis, PEP rates were higher in the SEMS group (8.0 %) versus the PS group (4.8 %) (OR 2.27 [CI, 1.22, 4.24]) for all obstructions. For malignant obstructions, PEP rates were 7.8 % and 6.6 % for SEMS and plastic stents, respectively (OR 1.54 [CI, 0.72, 3.30]). For benign obstructions the PEP rate was higher in the SEMS group (8.8 %) compared to the PS group (4.2 %) (OR 3.67 [CI, 1.50, 8.97]). No significant differences between PEP severity were identified based on stent type when stratified based on benign and malignant. Conclusions PEP rates were higher when SEMS were used for benign obstruction as compared to PS. For malignant obstruction, no difference was identified in PEP rates with use of SEMS vs PS.

Gastrointestinal bleeding in hospitalized COVID-19 patients: a propensity score matched cohort study.

BACKGROUND AND AIMS: Gastrointestinal (GI) bleeding has been observed amongst patients hospitalized with COVID-19. Recently, anticoagulation has shown to decrease mortality, but it is unclear whether this contributes to increased GI bleeding. The aims of this study are: (i) to examine whether there are risk factors for GI bleeding in COVID-19 patients and (ii) to study whether there is a mortality difference between hospitalized patients with COVID-19 with and without GI bleeding. METHODS: This is a propensity score matched case-control study from a large health system in the New York metropolitan area between March 1st and April 27th. COVID-19 patients with GI bleeding were matched 1:1 to COVID-19 patients without bleeding using a propensity score that took into account comorbidities, demographics, GI bleeding risk factors and length of stay. RESULTS: Of 11, 158 hospitalized with COVID-19, 314 patients were identified with GI bleeding. The point prevalence of GI bleeding was 3%. There were no identifiable risk factors for GI bleeding. Use of anticoagulation medication or antiplatelet agents was not associated with increased risk of GI bleeding in COVID-19 patients. For patients who developed a GI bleed during the hospitalization, there was an increased mortality risk in the GI bleeding group (OR 1.58, P = 0.02). CONCLUSION: Use of anticoagulation or antiplatelet agents was not risk factors for GI bleeding in a large cohort of hospitalized COVID-19 patients. Those with GI bleeding during the hospitalization had increased mortality.

Telemedicine for Disparity Patients With Diabetes: The Feasibility of Utilizing Telehealth in the Management of Uncontrolled Type 2 Diabetes in Black and Hispanic Disparity Patients; A Pilot Study.

BACKGROUND: Non-Hispanic Black (NHB) and Hispanic/Latinx (H/L) patients bear a disproportionate burden of type 2 diabetes and associated complications. Regular visits to a primary care doctor or diabetes specialist are warranted to maintain glycemic control, but for a myriad of reasons disparity populations may have difficulties receiving diabetes care. We seek to determine the feasibility of telehealth added to care as usual and secondarily to improve health outcomes (hemoglobin A1c [HbA1c]) in NHB and H/L with uncontrolled type 2 diabetes managed with two or three noninsulin agents. METHODS: Twenty-nine patients were randomized to monthly phone calls or weekly to biweekly telehealth visits. Feasibility outcomes were summarized descriptively for the telehealth arm. Differences scores for A1C level and surveys were computed between baseline and three months and compared across arms using a two-sample t test or Mann-Whitney U test. RESULTS: Patients in the telehealth arm completed a median of eight visits (IQR: 5, 8), and 53% of those in the telephone arm completed 100% of their calls. Change in HbA1c was greater for those in the telephone arm (-2.57 vs -2.07%, P = .70) but the mean baseline HbA1c was higher in the telephone group (11.1% vs 10.3%). Although the change in HbA1c was not statistically different across arms, it was clinically significant. CONCLUSIONS: Augmenting care as usual with telehealth provided by telephone or tablet can be of benefit in improving glycemic control in NHB and H/L with type 2 diabetes. Larger studies need to explore this further.

Characteristics and risk factors associated with critical illness in pediatric COVID-19.

BACKGROUND: While much has been reported regarding the clinical course of COVID-19 in children, little is known regarding factors associated with organ dysfunction in pediatric COVID-19. We describe critical illness in pediatric patients with active COVID-19 and identify factors associated with PICU admission and organ dysfunction. This is a retrospective chart review of 77 pediatric patients age 1 day to 21 years admitted to two New York City pediatric hospitals within the Northwell Health system between February 1 and April 24, 2020 with PCR + SARS-CoV-2. Descriptive statistics were used to describe the hospital course and laboratory results and bivariate comparisons were performed on variables to determine differences. RESULTS: Forty-seven patients (61%) were admitted to the general pediatric floor and thirty (39%) to the PICU. The majority (97%, n = 75) survived to discharge, 1.3% (n = 1) remain admitted, and 1.3% (n = 1) died. Common indications for PICU admission included hypoxia (50%), hemodynamic instability (20%), diabetic ketoacidosis (6.7%), mediastinal mass (6.7%), apnea (6.7%), acute chest syndrome in sickle cell disease (6.7%), and cardiac dysfunction (6.7%). Of PICU patients, 46.7% experienced any significant organ dysfunction (pSOFA > = 2) during admission. Patients aged 12 years or greater were more likely to be admitted to a PICU compared to younger patients (p = 0.015). Presence of an underlying comorbidity was not associated with need for PICU admission (p = 0.227) or organ dysfunction (p = 0.87). Initial white blood cell count (WBC), platelet count, and ferritin were not associated with need for PICU admission. Initial C-reactive protein was associated with both need for PICU admission (p = 0.005) and presence of organ dysfunction (p = 0.001). Initial WBC and presenting thrombocytopenia were associated with organ dysfunction (p = 0.034 and p = 0.003, respectively). CONCLUSIONS: Age over 12 years and initial CRP were associated with need for PICU admission in COVID-19. Organ dysfunction was associated with elevated admission CRP, elevated WBC, and thrombocytopenia. These factors may be useful in determining risk for critical illness and organ dysfunction in pediatric COVID-19.

EUS assessment for intermediate risk of choledocholithiasis after a negative magnetic resonance cholangiopancreatography.

BACKGROUND AND AIMS: Guidelines recommend either EUS or magnetic resonance cholangiopancreatography (MRCP) for intermediate risk of choledocholithiasis. There is a lack of evidence that supports proceeding with EUS if the MRCP is negative and if clinical suspicion still exists. METHODS: This is a retrospective study of all patients who underwent EUS to assess for choledocholithiasis at a tertiary care referral center from July 2013 to October 2019. RESULTS: A total of 593 patients underwent EUS for evaluation for choledocholithiasis. Of the 593 patients, 35.2% (209/593) had an MRCP. 73.2% (153/209) had a negative MRCP while 26.8% (56/209) had a positive MRCP. Of the group of patients who underwent EUS with a negative MRCP, 15% (23/153) were positive for choledocholithiasis on EUS. Of these, 91% (21/23) were also positive for sludge or stones on endoscopic retrograde cholangiopancreatography and thus 14% (21/153) of the EUS were "true positives." There were no clinical or laboratory factors predictive of choledocholithiasis on univariate analysis in the EUS plus negative MRCP group. When further analyzing the MRCP negative group into MRCP-/EUS+ and MRCP-/EUS-subgroups, a total bilirubin >3 mg/dL predicted a bile duct stone (55% vs. 32%, P = 0.05). CONCLUSION: The diagnostic yield of EUS for suspected choledocholithiasis in the setting of a negative MRCP is 14% in our cohort. EUS should be considered in patients with intermediate risk of choledocholithiasis with a negative MRCP if the clinical suspicion is still present, and especially if the total bilirubin is above 3 mg/dL.