Detection of atrial fibrillation by implantable loop recorders following cryptogenic stroke: A retrospective study of predictive factors and outcomes.

PURPOSE: Cryptogenic strokes account for 40% of ischemic strokes. Atrial fibrillation (AF) is a known cause of stroke. Current data shows that occult AF is detected by implantable devices at higher rates than conventional monitoring. The objective of this study was to investigate risk factors and outcomes associated with AF detection by implantable loop recorders (ILRs) in patients with cryptogenic stroke. METHODS: We conducted a retrospective study of 172 patients admitted with cryptogenic stroke at Ascension St John and Macomb-Oakland Hospitals who had ILRs placed from 1/1/2016 to 1/31/2020. AF detection was defined as sustained AF for 30 s. RESULTS: The incidence of AF detection by ILR was 14% (24/172) over a mean follow-up of 12.75 ± 10.71 months. The mean duration of monitoring prior to AF detection was 4.5 months. The median duration of AF was 6 min. With univariable analysis, older age (p = 0.03), male sex (p = 0.09), embolic stroke pattern on imaging (p = 0.06), and presence of symptoms (p = 0.001) were associated with AF detection. Using multivariable analysis, patients with AF were more likely to be older (OR = 1.04, p = 0.04), male (OR = 3.6, p = 0.03), symptomatic (OR = 6.3, p = 0.01), and had embolic stroke pattern (OR = 3.3, p = 0.04). 95.8% of patients with AF were started on anticoagulation for secondary stroke prevention. CONCLUSION: In patients with cryptogenic stroke, age, sex, stroke pattern, and presence of AF symptoms are independent predictors of AF detection by ILR. Most patients with AF were started on anticoagulation for secondary stroke prevention.

Coronavirus disease 2019 (COVID-19) and the risk of hypertensive disorders of pregnancy: a retrospective cohort study.

Objective: To evaluate of COVID-19 disease in pregnant women and its association with hypertensive disorders of pregnancy.Design: Retrospective Cohort StudySetting: Multicenter study from a large metropolitan hospital systemMethods: Patients who tested positive for COVID-19 during their pregnancy and delivered were compared to the three subsequent deliveries of patients who tested negative (controls). We evaluated the impact of COVID-19 on the development of hypertensive disorders of pregnancy.Results: Compared with pregnancies negative for SARs-CoV-2 infection, maternal SARs-CoV-2 infection was associated with an increased risk for hypertensive disorders of pregnancy (OR 3.68, 95% CI 1.67 - 8.10).Tweetable AbstractPatients who test positive for COVID-19 during their pregnancy are at increased risk of developing a hypertensive disorder of pregnancy. Earlier SARs-CoV-2 infection results in an increased risk of developing a hypertensive disorder.

Clinical Features and Risk Factors for In-Hospital Mortality From COVID-19 Infection at a Tertiary Care Medical Center, at the Onset of the US COVID-19 Pandemic.

BACKGROUND: Mortality from COVID-19 has been associated with older age, black race, and comorbidities including obesity, Understanding the clinical risk factors and laboratory biomarkers associated with severe and fatal COVID-19 will allow early interventions to help mitigate adverse outcomes. Our study identified risk factors for in-hospital mortality among patients with COVID-19 infection at a tertiary care center, in Detroit, Michigan. METHODS: We conducted a single-center, retrospective cohort study at a 776-bed tertiary care urban academic medical center. Adult inpatients with confirmed COVID-19 (nasopharyngeal swab testing positive by real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay) from March 8, 2020, to June 14, 2020, were included. Clinical information including the presence of comorbid conditions (according to the Charlson Weighted Index of Comorbidity (CWIC)), initial vital signs, admission laboratory markers and management data were collected. The primary outcome was in-hospital mortality. RESULTS: Among 565 hospitalized patients, 172 patients died for a case fatality rate of 30.4%. The mean (SD) age of the cohort was 64.4 (16.2) years, and 294 (52.0%) were male. The patients who died were significantly older (mean [SD] age, 70.4 [14.1] years vs 61.7 [16.1] years; P < 0.0001), more likely to have congestive heart failure (35 [20.3%] vs 47 [12.0%]; P = 0.009), dementia (47 [27.3%] vs 48 [12.2%]; P < 0.0001), hemiplegia (18 [10.5%] vs 18 [4.8%]; P = 0.01) and a diagnosis of malignancy (16 [9.3%] vs 18 [4.6%]; P = 0.03).From multivariable analysis, factors associated with an increased odds of death were age greater than 60 years (OR = 2.2, P = 0.003), CWIC score (OR = 1.1, P = 0.023), qSOFA (OR = 1.7, P < 0.0001), WBC counts (OR = 1.1, P = 0.002), lymphocytopenia (OR = 2.0, P = 0.003), thrombocytopenia (OR = 1.9, P = 0.019), albumin (OR = 0.6, P = 0.014), and AST levels (OR = 2.0, P = 0.004) on admission. CONCLUSIONS: This study identified risk factor for in-hospital mortality among patients admitted with COVID-19 in a tertiary care hospital at the onset of U.S. Covid-19 pandemic. After adjusting for age, CWIC score, and laboratory data, qSOFA remained an independent predictor of mortality. Knowing these risk factors may help identify patients who would benefit from close observations and early interventions.

Do risk factors at the time of hospital admission differ by sex for in-hospital mortality from coronavirus disease 2019 (COVID-19)?

Background: Sex-disaggregated data for coronavirus disease 2019 (COVID-19) reported higher hospitalized fatality rates among men than women. Objective: To determine whether the risk factors for in-hospital mortality from COVID-19, present at the time of hospital admission, differed by patient sex. Design and setting: Single-center, retrospective cohort study at a tertiary-care urban academic center. Methods: We reviewed the electronic medical records of patients positive for COVID-19 via qualitative polymerase chain reaction (PCR) assay, admitted between March 8 and June 14, 2020. Patients were stratified by sex to assess the association of variables present on admission with in-hospital mortality. Results: The overall inpatient case fatality rate (CFR) was 30.4% (172 of 565). The CFR among male patients was higher than among female patients: 99 (33.7%) versus 73 (26.9%), respectively (P = .08). Among males, comorbid conditions associated with in-hospital mortality were chronic pulmonary disease (P = .02) and connective tissue disease (P = .03). Among females, these comorbid conditions were congestive heart failure (P = .03), diabetes with complication (P = .05), and hemiplegia (P = .02). Variables that remained independently associated with death in males included age >70 years, public insurance, incremental increase in quick sepsis-related organ failure assessment (qSOFA) and C-reactive protein (CRP), lymphocytopenia, and thrombocytopenia. Among females, variables that remained independently associated with mortality included public insurance, incremental increase in Charlson weighted index of comorbidity (CWIC) score, qSOFA, and CRP. Conclusions: Risk factors for in-hospital mortality by sex included public insurance type, incremental increase in qSOFA and CRP in both sexes. For male patients, older age, lymphocytopenia and thrombocytopenia were also associated with mortality, whereas a higher Charlson score was associated with in-hospital mortality in female patients.

Risk Factors for In-hospital Mortality from Coronavirus Disease 2019 Infection Among Black Patients-An Urban Center Experience.

BACKGROUND: Racial disparities are central in the national conversation about coronavirus disease 2019 (COVID-19) , with Black/African Americans being disproportionately affected. We assessed risk factors for death from COVID-19 among Black inpatients at an urban hospital in Detroit, Michigan. METHODS: This was a retrospective, single-center cohort study. We reviewed the electronic medical records of patients positive for severe acute respiratory syndrome coronavirus 2 (the COVID-19 virus) on qualitative polymerase chain reaction assay who were admitted between 8 March 2020 and 6 May 2020. The primary outcome was in-hospital mortality. RESULTS: The case fatality rate was 29.1% (122/419). The mean duration of symptoms prior to hospitalization was 5.3 (3.9) days. The incidence of altered mental status on presentation was higher among patients who died than those who survived, 43% vs 20.0%, respectively (P < .0001). From multivariable analysis, the odds of death increased with age (≥60 years), admission from a nursing facility, Charlson score, altered mental status, higher C-reactive protein on admission, need for mechanical ventilation, presence of shock, and acute respiratory distress syndrome. CONCLUSIONS: These demographic, clinical, and laboratory factors may help healthcare providers identify Black patients at highest risk for severe COVID-19-associated outcomes. Early and aggressive interventions among this at-risk population may help mitigate adverse outcomes.

Predictors for Severe COVID-19 Infection.

BACKGROUND: COVID-19 is a pandemic disease caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Predictors for severe COVID-19 infection have not been well defined. Determination of risk factors for severe infection would enable identifying patients who may benefit from aggressive supportive care and early intervention. METHODS: We conducted a retrospective observational study of 197 patients with confirmed COVID-19 admitted to a tertiary academic medical center. RESULTS: Of 197 hospitalized patients, the mean (SD) age of the cohort was 60.6 (16.2) years, 103 (52.3%) were male, and 156 (82.1%) were black. Severe COVID-19 infection was noted in 74 (37.6%) patients, requiring intubation. Patients aged above 60 were significantly more likely to have severe infection. Patients with severe infection were significantly more likely to have diabetes, renal disease, and chronic pulmonary disease and had significantly higher white blood cell counts, lower lymphocyte counts, and increased C-reactive protein (CRP) than patients with nonsevere infection. In multivariable logistic regression analysis, risk factors for severe infection included pre-existing renal disease (odds ratio [OR], 7.4; 95% CI, 2.5-22.0), oxygen requirement at hospitalization (OR, 2.9; 95% CI, 1.3-6.7), acute renal injury (OR, 2.7; 95% CI, 1.3-5.6), and CRP on admission (OR, 1.006; 95% CI, 1.001-1.01). Race, age, and socioeconomic status were not independent predictors. CONCLUSIONS: Acute or pre-existing renal disease, supplemental oxygen upon hospitalization, and admission CRP were independent predictors for the development of severe COVID-19. Every 1-unit increase in CRP increased the risk of severe disease by 0.06%.

Patient Knowledge of Sunscreen Guidelines and Frequency of Physician Counseling: A Cross-sectional Study.

Background: Skin cancer and photodamage are problems commonly addressed by dermatologists. Despite the opportunities for chemoprevention with broad-spectrum sunscreen, there is little research investigating patient knowledge of proper sunscreen guidelines, or patient perception of physician counseling. Objective: The author sought to determine patient knowledge of the American Academy of Dermatology guidelines for proper sunscreen use and to obtain patient-reported rates of physician counseling regarding sunscreen. Design: We used a 12-question, multiple choice, anonymous survey to collect data. Setting: The study setting was a private dermatology clinic near Detroit, Michigan. PARTICIPANTS: Two hundred ninety- four adult patients presenting for routine office visits were included in the study. Results: About 59 percent of the subjects selected the recommended frequency of proper sunscreen use and 60 percent selected the recommended minimum sun protection factor. The minimum amount of sunscreen to cover the body, time of application before sun exposure, and time between reapplications of sunscreen did not receive a majority response. Differences in knowledge were seen between the sexes and skin types. Forty-four percent of patients previously received sunscreen counseling. Patients older than 40 years of age (39.3% vs. 18.4%, p=0.04), those who were fair skinned (62.5% vs. 23.8%), established patients (40.7% vs. 8.3%, p <0.0001), and those with a skin cancer (58.3% vs. 28%, p<0.0001) were more likely to report previous counseling. Conclusions: The majority of the study subjects never received counseling and lacked adequate knowledge of sunscreen guidelines. In order to obtain adequate primary prevention of skin cancer, it is essential to provide patients with further counseling and education on proper sunscreen use.

Avoiding potential harm by improving appropriateness of urinary catheter use in 18 emergency departments.

STUDY OBJECTIVE: Urinary catheters are often placed in the emergency department (ED) and are associated with an increased safety risk for hospitalized patients. We evaluate the effect of an intervention to reduce unnecessary placement of urinary catheters in the ED. METHODS: Eighteen EDs from 1 health system underwent the intervention and established institutional guidelines for urinary catheter placement, provided education, and identified physician and nurse champions to lead the work. The project included baseline (7 days), implementation (14 days), and postimplementation (6 months, data sampled 1 day per month). Changes in urinary catheter use, indications for use, and presence of physician order were evaluated, comparing the 3 periods. RESULTS: Sampled patients (13,215) admitted through the ED were evaluated, with 891 (6.7%; 95% confidence interval [CI] 6.3% to 7.2%) having a catheter placed. Newly placed catheters decreased from 309 of 3,381 (9.1%) baseline compared with 424 of 6,896 (6.1%) implementation (Δ 3.0%; 95% CI 1.9% to 4.1%), and 158 of 2,938 (5.4%) postimplementation periods (Δ 3.8%; 95% CI 2.5% to 5.0%). The appropriateness of newly placed urinary catheters improved from baseline (228/308; 74%) compared with implementation (385/421; 91.4%; Δ 17.4%; 95% CI 11.9% to 23.1%) and postimplementation periods (145/158; 91.8%; Δ 23.9%; 95% CI 18% to 29.3%). Physician order documentation in the presence of the urinary catheter was 785 of 889 (88.3%), with no visible change over time. Improvements were noted for different-size hospitals and were more pronounced for hospitals with higher urinary catheter placement baseline. CONCLUSION: The implementation of institutional guidelines for urinary catheter placement in the ED, coupled with the support of clearly identified physician and nurse champions, is associated with a reduction in unnecessary urinary catheter placement. The effort has a substantial potential of reducing patient harm hospital-wide.

Alcohol and trauma--in every age group.

BACKGROUND: The purpose was to determine the proportion of alcohol-positive (AlcPos) trauma patients in different age groups and any association with mortality using the National Trauma Data Bank. METHODS: Several variables were extracted from the National Trauma Data Bank (version 6.2) using MS Access 2007: age, alcohol presence, Injury Severity Score (ISS), and discharge status (alive vs dead). Age groups for logistic regression were arbitrarily defined as follows: 0 to 10, 11 to 20, 21 to 39, 40 to 64, and older than 64 years. RESULTS: Approximately 47% of all trauma survivors were tested for alcohol (621,174 of a total of 1,311,137), and 28% of those were AlcPos (176,107/621,174). The proportion of AlcPos patients gradually increased to maximum at 22 years, when 46% (6797/14,732) tested were AlcPos. The proportion AlcPos gradually declined to 35% by age 50 years, then to 15% (2516/16,244) by age 66 to 70 years. The ISSs were significantly higher in AlcPos patients in all age groups (P < .01). Mortality rates were higher in AlcPos children (up to age 20 years) and in adults older than 40 years. The AlcPos patients who were 21 to 39 years old had lower mortality compared with alcohol-negative patients. Logistic regression analysis (controlling for ISSs) revealed that being AlcPos did not play a role in mortality until age 21 to 39 years (AlcPos lower mortality) and in age 40 to 64 years and older than 65 years (AlcPos higher mortality). CONCLUSIONS: Trauma patients of all ages may be AlcPos. Being AlcPos is a marker for greater injury in all age groups. After controlling for ISSs, trauma patients 40 years and older who were AlcPos have increased mortality. This study suggests a role for alcohol testing in all age groups.

Awareness of kidney disease and relationship to end-stage renal disease and mortality.

BACKGROUND: Often, patients with chronic kidney disease are reported to be unaware of it. We prospectively evaluated the association between awareness of kidney disease to end-stage renal disease and mortality. METHODS: We utilized 2000-2009 data from the National Kidney Foundation's Kidney Early Evaluation Program. Mortality was determined by cross reference to the Social Security Administration Death Master File and development of end stage by cross reference with the United States Renal Data System. RESULTS: Of 109,285 participants, 28,244 (26%) had chronic kidney disease defined by albuminuria or estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2). Only 9% (n=2660) reported being aware of kidney disease. Compared with those who were not aware, participants aware of chronic kidney disease had lower eGFR (49 vs 62 mL/min/1.73 m(2)) and a higher prevalence of albuminuria (52% vs. 46%), diabetes (47% vs 42%), cardiovascular disease (43% vs 28%), and cancer (23% vs 14%). Over 8.5 years of follow-up, aware participants compared with those unaware had a lower rate of survival for end stage (83% and 96%) and mortality (78% vs 81%), P <.001. After adjustment for demographics, socioeconomic factors, comorbidity, and severity of kidney disease, aware participants continued to demonstrate an increased risk for end-stage renal disease (hazard ratio 1.37; 95% confidence interval, 1.07-1.75; P <.0123) and mortality (hazard ratio 1.27; 95% confidence interval, 1.07-1.52; P <.0077) relative to unaware participants with chronic kidney disease. CONCLUSIONS: Among patients identified as having chronic kidney disease at a health screening, only a small proportion had been made aware of their diagnosis previously by clinicians. This subgroup was at a disproportionately high risk for mortality and end-stage renal disease.

Differences in patient risk factors and source of candidaemia caused by Candida albicans and Candida glabrata.

There is an increasing frequency of candidaemia caused by Candida glabrata which has decreased in vitro susceptibility to fluconazole. Differences in risk factors for candidaemia caused by C. glabrata and C. albicans have not been formally evaluated in a diverse patient group. We performed a retrospective study of adult inpatients from January 1, 2003 to April 30, 2008 with C. glabrata and C. albicans candidaemia at a single tertiary care centre in Detroit, Michigan to evaluate for differences in risk factors and presumed source of infection in these groups. Patients' underlying conditions, risk factors and source of infection (probable or definite) were compared. Among 119 patients, 80 (67.2%) were C. albicans and 39 (32.8%) C. glabrata. Using logistic regression analysis, patients with C. glabrata infection were more likely to have diabetes mellitus (OR 2.43; 95% CI, 1.06-5.54) and abdominal source of infection (OR 4.53, 95% CI, 1.72-11.92). Mortality rates in the two groups were similar. Patients with C. glabrata candidaemia are more likely to be diabetic and have an abdominal source of infection compared with patients with C. albicans.