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Introduction: Pain is a major driver of visits to the emergency department (ED). Clinicians must consider not only the efficacy of treatment options but also subsequent healthcare utilization and patient-centered outcomes such as side effects from prescribed medications. Our goal in this study was to determine whether there was an association between acute pain treatment regimen (opioids, intranasal non-steroidal anti-inflammatory drugs [NSAIDs], or both) and unscheduled healthcare visits following ED discharge.Methods: This study was a secondary analysis of the Acute Management of Pain from the Emergency Department (AMPED) prospective, observational cohort study. We used Cox proportional hazards analysis to assess the relationship between treatment regimen and time to first unscheduled healthcare visit. Repeated measures logistic regression analyses were used to determine the relationship between treatment regimen and any unscheduled visits, and to evaluate whether this relationship was mediated by pain severity and/or medication side effects.Results: Of 831 total enrolled participants, 141 (16.9%) experienced an unplanned healthcare visit within five days of ED discharge. A majority of these visits happened one day after the ED visit. Those who were treated with intranasal NSAIDs only were less likely to have an unscheduled healthcare visit compared to those who received opioids only, with an adjusted odds ratio (AOR) of 0.63. The higher odds of unscheduled healthcare visits with opioids were mediated by both the presence of side effects and higher pain levels, with AORs of 2.24 and 1.33, respectively.Conclusion: Opioid treatment for acute pain is associated with increased unscheduled healthcare visits compared to those treated with intranasal ketorolac. This difference can be explained by higher levels of ongoing pain and greater medication side effects.

Background: Farm-to-University (Farm2U) programs make healthy eating accessible, easier, and the default option. Yet, few published studies have focused on Farm2U implementations in Historically Black Colleges and Universities (HBCUs) in conjunction with measurements of implementation barriers using the consolidated framework for implementation research (CFIR). Purpose: The purpose of this study was to assess the feasibility of delivering a Farm2U program in four HBCUs in North Carolina. Methods: Using a quasi-experimental pre-posttest design, four HBCUs were allocated to either the intervention or the control group. The program was administered over a 4-month period and data were collected at baseline and at post-program implementation. Results: With a target sample size of 128, we successfully recruited 351 participants, retaining 138 at follow-up, for a retention rate of 39%. Twelve CFIR constructs were measured, ten emerged as facilitators and two as mixed barriers/facilitators to program implementation. We observed an increase in local produce purchases and a significant increase in the daily intake of fruits for students. Discussion: This study demonstrated that a Farm2U program is feasible in HBCUs. Translation to Health Education Practice: Certified Health Education Specialists can use the findings to implement Farm2U programs that promote healthy food environments in school settings.

Introduction: Triage functions to quickly prioritize care and sort patients by anticipated resource needs. Despite widespread use of the Emergency Severity Index (ESI), there is still no universal standard for emergency department (ED) triage. Thus, it can be difficult to objectively assess national trends in ED acuity and resource requirements. We sought to derive an ESI from National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items (NHAMCS-ESI) and to assess the performance of this index with respect to stratifying outcomes, including hospital admission, waiting times, and ED length of stay (LOS).Methods: We used data from the 2010-2015 NHAMCS, to create a measure of ED visit complexity based on variables within NHAMCS. We used NHAMCS data on chief complaint, vitals, resources used, interventions, and pain level to group ED visits into five levels of acuity using a stepwise algorithm that mirrored ESI. In addition, we examined associations of NHAMCS-ESI with typical indicators of acuity such as waiting time, LOS, and disposition. The NHAMCS-ESI categorization was also compared against the “immediacy” variable across all of these outcomes. Visit counts used weighted scores to estimate national levels of ED visits.Results: The NHAMCS ED visits represent an estimated 805,726,000 ED visits over this time period. NHAMCS-ESI categorized visits somewhat evenly, with most visits (42.5%) categorized as a level 3. The categorization pattern is distinct from that of the “immediacy” variable within NHAMCS. Of admitted patients, 89% were categorized as NHAMCS-ESI level 2-3. Median ED waiting times increased as NHAMCS-ESI levels decreased in acuity (from approximately 14 minutes to 25 minutes). Median LOS decreased as NHAMCS-ESI decreased from almost 200 minutes for level 1 patients to nearly 80 minutes for level 5 patients.Conclusion: We derived an objective tool to measure an ED visit’s complexity and resource use. This tool can be validated and used to compare complexity of ED visits across hospitals and regions, and over time.

Background: Thyroid nodules are challenging to accurately characterize on ultrasound (US), though the emergence of risk stratification systems and more recently artificial intelligence (AI) algorithms has improved nodule classification. The purpose of this study was to evaluate the performance of a recent Food and Drug Administration (FDA)-cleared AI tool for detection of malignancy in thyroid nodules on US. Methods: One year of consecutive thyroid US with ≥1 nodule from Duke University Hospital and its affiliate community hospital (649 nodules from 347 patients) were retrospectively evaluated. Included nodules had ground truth diagnoses by surgical pathology, fine needle aspiration (FNA), or three-year follow-up US showing stability. An FDA-cleared AI tool (Koios DS Thyroid) analyzed each nodule to generate (i) American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) descriptors, scores, and follow-up recommendations and (ii) an AI-adapter score to further adjust risk assessments and recommendations. Four groups were then compared: (i) Koios with AI-adapter, (ii) Koios without AI-adapter, (iii) clinical radiology report, and (iv) radiology report combined with AI-adapter. Performance of the final recommendations (FNA or no FNA) was determined based on ground truth, and comparison between the four groups was made using sensitivity, specificity, and receiver-operating-curve analysis. Results: Of 649 nodules, 32 were malignant and 617 were benign. Performance of Koios with AI-adapter enabled was similar to radiologists (area under the curve [AUC] 0.70 for both, [CI 0.60–0.81] and [0.60–0.79], respectively). Koios with AI-adapter had improved specificity compared to radiologists (0.63 [CI: 0.59–0.67] versus 0.43 [CI: 0.38–0.48]) but decreased sensitivity (0.69 [CI: 0.50–0.83) versus 0.81 [CI: 0.61, 0.92]). Highest performance was seen when the radiology interpretation was combined with the AI-adapter (AUC 0.76, [CI: 0.67–0.85]). Combined with the AI-adapter, radiologist specificity improved from 0.43 ([CI: 0.38–0.48]) to 0.53 ([CI: 0.49–0.58]) (McNemar's test p < 0.001), resulting in 17% fewer FNA recommendations, with unchanged sensitivity (0.81, p = 1). Conclusion: Koios DS demonstrated standalone performance similar to radiologists, though with lower sensitivity and higher specificity. Performance was best when radiologist interpretations were combined with the AI-adapter component, with improved specificity and reduced unnecessary FNA recommendations. [ABSTRACT FROM AUTHOR]

Background: In kidney transplantation, concerns have been raised regarding increased incidence of viral opportunistic infections in hepatitis C virus (HCV) nucleic acid test (NAT)‐negative (‐) recipients who received HCV NAT‐positive (+) donor kidneys, specifically BK polyomavirus (BKPyV), cytomegalovirus (CMV), and Epstein‐Barr virus (EBV). The purpose of this study was to determine the incidence of these three viral opportunistic infections in HCV NAT‐ recipients who have undergone kidney transplantation with HCV NAT+ donor kidneys at our institution. Methods: This was an Institutional Review Board‐approved, single‐center, retrospective case‐control study of HCV NAT‐ kidney transplant recipients with HCV NAT+ donors from 2018 to 2021. The primary outcome was the cumulative incidence of viral infections of BKPyV, CMV, and/or EBV within 1 year following kidney transplantation. Results: A total of 231 patients were included, 77 in the exposed (donor HCV NAT+) group and 154 in the control (donor HCV NAT‐) group. The adjusted cumulative incidence of viremia within 1 year did not statistically differ between groups (77% exposed group versus 66% for the control group, hazard ratio 1.34, 95% confidence interval 0.95–1.89). In addition, no statistically significant differences were observed for secondary outcomes with the exception of CMV viremia (62% exposed versus 49% control, p = 0.021). However, there were more patients in the exposed group at high risk for CMV viremia based on serostatus (CMV Donor+/Recipient‐, D+/R‐). Conclusion: Among patients who received HCV NAT+ donor kidneys, no clear association was observed between exposure to HCV NAT+ donor kidneys and viral infections of BKPyV, CMV, or EBV. [ABSTRACT FROM AUTHOR]

Objectives: Tacrolimus remains the mainstay of immunosuppression in kidney transplantation. Understanding the relationship between therapeutic tacrolimus levels and outcomes of acute rejection, patient/graft survival, and tolerability are important. The relationship between time to therapeutic tacrolimus levels and outcomes has not been well established, specifically with the use of extended release tacrolimus formulation (LCP-Tac). This study investigated time to therapeutic tacrolimus levels of 2 tacrolimus formulations, LCP-Tac and immediate release tacrolimus (IR-Tac), as a predictor of clinical outcomes. Methods: This was a single-center, retrospective, cohort study of kidney transplant recipients at Duke Hospital between 2013-2021. The primary objective evaluated the difference in time to therapeutic tacrolimus levels with LCP-Tac vs IR-Tac regimens. Secondary endpoints included time within therapeutic range during the first 3 months post-transplant, incidence of biopsy-proven rejection, development of de novo donor specific antibodies, and patient and allograft survival at 12 months post-transplant. Results: 128 patients were included (63 in LCP-Tac group and 65 in IR-Tac group). The time to therapeutic tacrolimus level was similar between formulations (7.2 days with LCP-Tac compared to 6.7 days with IR-Tac, P =.63). The time within therapeutic range during the first 3 months post-transplant, via modified Rosendaal, was similar with LCP-Tac and IR-Tac (56.1% vs 64.8%, respectively). Rates of biopsy-proven acute rejection at 12 months were similar (7/63 (11.1%) compared to 4/65 (6.2%)). There was no difference in patient/graft survival between groups. Conclusions: The time to therapeutic tacrolimus levels did not differ based on tacrolimus formulation and was not correlated with clinical outcomes. [ABSTRACT FROM AUTHOR]

Observational studies in adults suggest nasal methicillin-resistant Staphylococcus aureus (MRSA) swabs have a high negative predictive value (NPV) for ruling out MRSA pneumonia, however, pediatric data are limited. This retrospective study of 505 pediatric patients found a 99.8% NPV among children with suspected respiratory infections. [ABSTRACT FROM AUTHOR]

BACKGROUND: Pembrolizumab and nivolumab are PD-1–blocking antibodies that are FDAapproved for a variety of malignancies. Previously, only 1 fixed dosing schedule was approved for these agents, with nivolumab dosed at 240 mg intravenously (IV) every 2 weeks and pembrolizumab dosed at 200 mg IV every 3 weeks. Recently, the FDA approved an alternate dosing schedule for nivolumab dosed at 480 mg IV every 4 weeks and pembrolizumab dosed at 400 mg IV every 6 weeks following the results of pharmacokinetic simulation models that showed a similar risk-benefit profile based on a relatively small sample size. OBJECTIVE: To compare the incidence of immune-related adverse events (irAEs) and infusion reactions of different FDA-approved dosing regimens for nivolumab and pembrolizumab. METHODS: This single-center, retrospective chart review included 171 adults with cancer who received at least 2 doses of nivolumab or pembrolizumab at either dosing schedule for any diagnosis of cancer at Duke University Health System between January 1, 2018, and June 30, 2021. The primary end point was the incidence of any-grade irAEs occurring in each of the 4 study groups (nivolumab 240 mg IV every 2 weeks, nivolumab 480 mg IV every 4 weeks, pembrolizumab 200 mg IV every 3 weeks, and pembrolizumab 400 mg IV every 6 weeks) within 6 months of treatment initiation. RESULTS: The incidence rates of any-grade irAEs were 40% for the patients who received nivolumab 240 mg IV every 2 weeks and 46% for the patients who received nivolumab 480 mg IV every 4 weeks. The rates of any-grade irAEs were 34% in the patients who received pembrolizumab 200 mg IV every 3 weeks and 47.6% in those who received pembrolizumab 400 mg IV every 6 weeks. Although the number of patients with irAEs was higher in the groups that received nivolumab 480 mg IV every 4 weeks or pembrolizumab 400 mg IV every 6 weeks, the incidence of irAEs was not significantly different between the group that received nivolumab 240 mg IV every 2 weeks versus nivolumab 480 mg IV every 4 weeks (P=.54, chi-square) and the group that received pembrolizumab 200 mg IV every 3 weeks versus pembrolizumab 400 mg IV every 6 weeks (P=.28, chi-square). The patients who received nivolumab 480 mg IV every 4 weeks had a higher incidence of infusion reactions than those who received nivolumab 240 mg IV every 2 weeks (10% vs 4%, respectively). Patients who received pembrolizumab 200 mg IV every 3 weeks had a higher incidence of infusion reactions than those who received pembrolizumab 400 mg IV every 6 weeks (6% vs 0%, respectively). CONCLUSION: The incidence of irAEs was not significantly different among patients receiving nivolumab or pembrolizumab at either dosing schedules. The incidence of infusion reactions was higher in the groups that received nivolumab 480 mg IV every 4 weeks or pembrolizumab 200 mg IV every 3 weeks than in the groups that received nivolumab 240 mg IV every 2 weeks or pembrolizumab 400 mg IV every 6 weeks. Further studies are warranted to validate these results. [ABSTRACT FROM AUTHOR]

Objectives: To describe population rate of hysterectomy for benign disease in the USA, including geographic variation across states and Hospital Service Areas (HSAs; areas defined by common patient flows to healthcare facilities). Design: Cross‐sectional study. Setting: Four US states including 322 HSAs. Population: A total of 316 052 cases of hysterectomy from 2012 to 2016. Methods: We compiled annual hysterectomy cases, merged female populations, and adjusted for reported rates of previous hysterectomy. We assessed small‐area variation and created multi‐level Poisson regression models. Main Outcome Measures: Prior‐hysterectomy‐adjusted population rates of hysterectomy for benign disease. Results: The annual population rate of hysterectomy for benign disease was 49 per 10 000 hysterectomy‐eligible residents, declining slightly over time, mostly among reproductive‐age populations. Rates peaked among residents ages 40–49 years, and declined with increasing age, apart from an increase with universal coverage at age 65 years. We found large differences in age‐standardised population rates of hysterectomy across states (range 42.2–69.0), and HSAs (range: overall 12.9–106.3; 25th–75th percentile 44.0–64.9). Among the non‐elderly population, those with government‐sponsored insurance had greater variation than those with private insurance (coefficient of variation 0.61 versus 0.32). Proportions of minimally invasive procedures were similar across states (71.0–74.8%) but varied greatly across HSAs (27–96%). In regression models, HSA population characteristics explained 31.8% of observed variation in annual rates. Higher local proportions of government‐sponsored insurance and non‐White race were associated with lower population rates. Conclusions: We found substantial variation in rate and route of hysterectomy for benign disease in the USA. Local population characteristics explained less than one‐third of observed variation. [ABSTRACT FROM AUTHOR]