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Extreme events such as hurricanes adversely impact healthcare systems and the communities they serve. The degree to which hurricanes affect healthcare use among high need groups such as older adults with chronic conditions has not been well examined, nor has the impact of hurricane severity on health outcomes. We characterized hospitalizations among older adults by chronic condition after eight large-scale hurricanes in the United States.Using a combination of administrative healthcare data and the Federal Emergency Management Agency's Disaster Declaration database we conducted a self-controlled case series analysis. We identified Medicare beneficiaries who were exposed to one of eight hurricanes and compared hospitalizations in the 30-days after a hurricane to hospitalizations in the rest of the calendar year of the hurricane. We examined hospitalizations (1) in total, (2) separately for diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) admissions, and (3) by hurricane damage category.Among all older adults exposed, hospitalizations in the 30-day period after each disaster increased for all three chronic conditions; diabetes (incidence rate ratio [IRR] = 1.06, 95% confidence interval [CI] 1.03, 1.10), COPD (IRR = 1.06, 95% CI 1.04, 1.08), and CHF (IRR = 1.19, 95% CI 1.17, 1.21. In the 30-to-60-day period hospitalizations also increased for each chronic condition; diabetes (IRR = 1.06, 95% CI 1.03, 1.10), COPD (IRR = 1.12, 95% CI 1.10, 1.15), and CHF (IRR = 1.32, 95% CI 1.30, 1.34). Substantial differences in hospitalizations were observed according to individual hurricane and by the chronic disease examined.Exposure to hurricanes is associated with an increase in hospitalizations for chronic conditions across all hurricane damage categories. As disasters are expected to increase in strength and frequency, our results underscore the need for response strategies and health policy planning for healthcare systems designed to address the health needs of older Americans with chronic conditions.

RationalePredicting long-term outcomes in sepsis survivors remains a difficult task. Persistent inflammation post-sepsis is associated with increased risk for rehospitalization and death. As surrogate markers of inflammation, complete blood count parameters measured at hospital discharge may have prognostic value for sepsis survivors.ObjectiveTo determine the incremental value of complete blood count parameters over clinical characteristics for predicting 90-day outcomes in sepsis survivors.MethodsElectronic health record data was used to identify sepsis hospitalizations at United States Veterans Affairs hospitals with live discharge and relevant laboratory data (2013 to 2018). We measured the association of eight complete blood count parameters with 90-day outcomes (mortality, rehospitalization, cause-specific rehospitalizations) using multivariable logistic regression models.Measurements and main resultsWe identified 155,988 eligible hospitalizations for sepsis. Anemia (93.6%, N=142,162) and lymphopenia (28.1%, N=29,365) were the most common blood count abnormalities at discharge. In multivariable models, all parameters were associated with the primary outcome of 90-day mortality or rehospitalization and improved model discrimination above clinical characteristics alone (likelihood ratio test, pConclusionsThe incorporation of discharge complete blood count parameters into prognostic scoring systems could improve prediction of 90-day outcomes. Hemoglobin had the greatest prognostic value for the primary composite outcome of 90-day rehospitalization or mortality. Absolute lymphocyte count provided little added value in multivariable model comparisons, including for infection- or sepsis-related rehospitalization.

Rationale: The Epic Deterioration Index (EDI) is a proprietary prediction model implemented in over 100 U.S. hospitals that was widely used to support medical decision-making during the coronavirus disease (COVID-19) pandemic. The EDI has not been independently evaluated, and other proprietary models have been shown to be biased against vulnerable populations. Objectives: To independently evaluate the EDI in hospitalized patients with COVID-19 overall and in disproportionately affected subgroups. Methods: We studied adult patients admitted with COVID-19 to units other than the intensive care unit at a large academic medical center from March 9 through May 20, 2020. We used the EDI, calculated at 15-minute intervals, to predict a composite outcome of intensive care unit–level care, mechanical ventilation, or in-hospital death. In a subset of patients hospitalized for at least 48 hours, we also evaluated the ability of the EDI to identify patients at low risk of experiencing this composite outcome during their remaining hospitalization. Results: Among 392 COVID-19 hospitalizations meeting inclusion criteria, 103 (26%) met the composite outcome. The median age of the cohort was 64 (interquartile range, 53–75) with 168 (43%) Black patients and 169 (43%) women. The area under the receiver-operating characteristic curve of the EDI was 0.79 (95% confidence interval, 0.74–0.84). EDI predictions did not differ by race or sex. When exploring clinically relevant thresholds of the EDI, we found patients who met or exceeded an EDI of 68.8 made up 14% of the study cohort and had a 74% probability of experiencing the composite outcome during their hospitalization with a sensitivity of 39% and a median lead time of 24 hours from when this threshold was first exceeded. Among the 286 patients hospitalized for at least 48 hours who had not experienced the composite outcome, 14 (13%) never exceeded an EDI of 37.9, with a negative predictive value of 90% and a sensitivity above this threshold of 91%. Conclusions: We found the EDI identifies small subsets of high-risk and low-risk patients with COVID-19 with good discrimination, although its clinical use as an early warning system is limited by low sensitivity. These findings highlight the importance of independent evaluation of proprietary models before widespread operational use among patients with COVID-19.

Identifying persons with hepatitis C virus (HCV) infection has become an urgent public health challenge because of increasing HCV-related morbidity and mortality, low rates of awareness among infected persons, and the advent of curative therapies (1). Since 2012, CDC has recommended testing of all persons born during 1945-1965 (baby boomers) for identification of chronic HCV infection (1); urban emergency departments (EDs) are well positioned venues for detecting HCV infection among these persons. The United States has witnessed an unprecedented opioid overdose epidemic since 2013 that derives primarily from commonly injected illicit opioids (e.g., heroin and fentanyl) (2). This injection drug use behavior has led to an increase in HCV infections among persons who inject drugs and heightened concern about increases in human immunodeficiency virus (HIV) and HCV infection within communities disproportionately affected by the opioid crisis (3,4). However, targeted strategies for identifying HCV infection among persons who inject drugs is challenging (5,6). During 2015-2016, EDs at the University of Alabama at Birmingham; Highland Hospital, Oakland, California; Johns Hopkins Hospital, Baltimore, Maryland; and Boston University Medical Center, Massachusetts, adopted opt-out (i.e., patients can implicitly accept or explicitly decline testing), universal hepatitis C screening for all adult patients. ED staff members offered HCV antibody (anti-HCV) screening to patients who were unaware of their status.* During similar observation periods at each site, ED staff members tested 14,252 patients and identified an overall 9.2% prevalence of positive results for anti-HCV among the adult patient population. Among the 1945-1965 birth cohort, prevalence of positive results for anti-HCV (13.9%) was significantly higher among non-Hispanic blacks (blacks) (16.0%) than among non-Hispanic whites (whites) (12.2%) (p

Objectives To determine if a correlation exists between 3 iphone pulse ox applications' measurements and the standard pulse oximetry (SpO2) and whether these applications can accurately determine hypoxia. Methods Three applications reportedly measuring SpO2 were downloaded onto an iPhone 5s. Two of these applications used the onboard light and camera lens “Pulse Oximeter” (Pox) and “Heart Rate and Pulse Oximeter” (Ox) and one used an external device that plugged into the iphone (iOx). Patients in the ED were enrolled with chief complaints of cardiac/pulmonary origin or a SpO2 ≤ 94%. All measurements were compared to controls. Concordance correlation coefficients, sensitivity, and specificity were calculated. Results A total of 191 patients were enrolled. The concordance correlation of iOx with control was 0.55 (CI 0.46, 0.63), POx was 0.01 (CI −0.09, 0.11), and Ox was 0.07 (CI −0.02, 0.15). 68/191 patients (35%) were found to have hypoxemia. Sensitivities for detecting hypoxia were 69%, 0%, and 7% for iOx, POx, and Ox, respectively. Specificities were 89%, 100%, and 89%. Even iOx (the most accurate) 21 (11%) were incorrectly classified nonhypoxic, and 22 (12%) were incorrectly classified hypoxic. Conclusions While iOx has modest concordance with control, Ox and POx showed almost none. The iOx device was best in correctly identifying hypoxia patients, but almost 1/4 of patients were incorrectly classified. The three apps provided inaccurate SpO2 measurements and had limited to no ability to accurately detect hypoxia. These apps should not be relied upon to provide accurate SpO2 measurements in emergent, even austere conditions.

2020 IPTC conference review The 12th International Petroleum Technology Conference, held 13–15 January in Dhahran, was the largest in its history with more than 18,000 attendees. It marked the first international multidisciplinary, intersociety oil and gas conference and exhibition to be held in Saudi Arabi and featured some of the globe’s top oil and gas executives, including the energy ministers of Saudi Arabia and Bahrain, Saudi Aramco’s president and CEO, and the CEOs of ExxonMobil, Total, Petronas, and Woodside. Below are highlights from some of the plenary, panel, and technical sessions that took place during the 3-day event. Welcoming a New Energy Era The conference opened with a distinguished panel offering its outlook for oil and gas markets in the next year and the next decade. “This is the first interdisciplinary oil and gas conference to be held in Saudi Arabia,” said Mahmoud M. Abdulbaqi, chairman of the board of ARGAS and chairman of the IPTC Board of Directors. The conference was hosted by Saudi Aramco. The opening panel included Abdulbaqi; Mohammed Y. Al-Qahtani, senior vice president, upstream, Saudi Aramco; Yasir Al-Rumayyan, chairman of the board, Saudi Aramco; and Prince Abdulaziz bin Salman Al-Saud, minister of energy, Kingdom of Saudi Arabia. “These are exiting times for the Kingdom,” al-Qahtani said, as both Saudi Aramco and the oil and gas industry at large face a new decade of growing demand but with a need to lighten the industry’s carbon footprint. Saudi Aramco raised a record $29.4 billion in its recent IPO. Al-Rumayyan said the oil and gas industry thinks in terms of decades, which runs up against the notion that the “energy transition” will occur “from a definitive point A to a definitive point B” and will take place at the same time in the same way everywhere. Instead, he offered what he called the “pragmatic narrative” of a transition happening over decades and that there “will be many energy transitions” at different speeds. The more narrow narrative is having negative consequences for the industry, he added, because it is influencing some banks to back away from funding oil and gas projects. This lack of investment eventually will lead to a supply shortage that could cause oil price spikes in the near future, he said. He acknowledged the need of the industry to “lighten the carbon footprint” through technology and innovation, but it must continue to meet the world’s energy needs. The industry must never forget its role to responsibly supply energy required to power the world and sustain economies, he said. If the industry “offers real solutions with real energy to meet real needs” it will last well into the future, he added. Saudi Energy Minister Al-Saud noted the historically important role that Saudi Arabia has played since the discovery of oil about 80 years ago. The global economic growth of the past half century, which paved the way for transformative development and lifted many out of poverty, would not have taken place without the stability of oil supply from Saudi Arabia.

ObjectiveTo create and validate a simple and transferable machine learning model from electronic health record data to accurately predict clinical deterioration in patients with covid-19 across institutions, through use of a novel paradigm for model development and code sharing.DesignRetrospective cohort study.SettingOne US hospital during 2015-21 was used for model training and internal validation. External validation was conducted on patients admitted to hospital with covid-19 at 12 other US medical centers during 2020-21.Participants33 119 adults (≥18 years) admitted to hospital with respiratory distress or covid-19.Main outcome measuresAn ensemble of linear models was trained on the development cohort to predict a composite outcome of clinical deterioration within the first five days of hospital admission, defined as in-hospital mortality or any of three treatments indicating severe illness: mechanical ventilation, heated high flow nasal cannula, or intravenous vasopressors. The model was based on nine clinical and personal characteristic variables selected from 2686 variables available in the electronic health record. Internal and external validation performance was measured using the area under the receiver operating characteristic curve (AUROC) and the expected calibration error—the difference between predicted risk and actual risk. Potential bed day savings were estimated by calculating how many bed days hospitals could save per patient if low risk patients identified by the model were discharged early.Results9291 covid-19 related hospital admissions at 13 medical centers were used for model validation, of which 1510 (16.3%) were related to the primary outcome. When the model was applied to the internal validation cohort, it achieved an AUROC of 0.80 (95% confidence interval 0.77 to 0.84) and an expected calibration error of 0.01 (95% confidence interval 0.00 to 0.02). Performance was consistent when validated in the 12 external medical centers (AUROC range 0.77-0.84), across subgroups of sex, age, race, and ethnicity (AUROC range 0.78-0.84), and across quarters (AUROC range 0.73-0.83). Using the model to triage low risk patients could potentially save up to 7.8 bed days per patient resulting from early discharge.ConclusionA model to predict clinical deterioration was developed rapidly in response to the covid-19 pandemic at a single hospital, was applied externally without the sharing of data, and performed well across multiple medical centers, patient subgroups, and time periods, showing its potential as a tool for use in optimizing healthcare resources.

Objective To determine whether surge conditions were associated with increased mortality. Design Multicenter cohort study. Setting U.S. ICUs participating in STOP-COVID. Patients Consecutive adults with COVID-19 admitted to participating ICUs between March 4 and July 1, 2020. Interventions None Measurements and Main Results The main outcome was 28-day in-hospital mortality. To assess the association between admission to an ICU during a surge period and mortality, we used two different strategies: (1) an inverse probability weighted difference-in-differences model limited to appropriately matched surge and non-surge patients and (2) a meta-regression of 50 multivariable difference-in-differences models (each based on sets of randomly matched surge- and non-surge hospitals). In the first analysis, we considered a single surge period for the cohort (March 23 – May 6). In the second, each surge hospital had its own surge period (which was compared to the same time periods in matched non-surge hospitals). Our cohort consisted of 4342 ICU patients (average age 60.8 [sd 14.8], 63.5% men) in 53 U.S. hospitals. Of these, 13 hospitals encountered surge conditions. In analysis 1, the increase in mortality seen during surge was not statistically significant (odds ratio [95% CI]: 1.30 [0.47-3.58], p = .6). In analysis 2, surge was associated with an increased odds of death (odds ratio 1.39 [95% CI, 1.34-1.43], p Conclusions Admission to an ICU with COVID-19 in a hospital that is experiencing surge conditions may be associated with an increased odds of death. Given the high incidence of COVID-19, such increases would translate into substantial excess mortality.

Key Points Question How has timing of antibiotics for sepsis changed over time in US Department of Veterans Affairs Hospitals? Findings In this cohort of 111 385 veterans hospitalized with sepsis from 2013 to 2018, median time to antibiotics declined by 9 minutes per year. However, there was significant variation in time to antibiotics across hospitals, even after adjustment for patient characteristics. Meaning These findings suggest that there is potential for performance improvement for sepsis hospitalizations, but efforts to further accelerate time-to-antibiotics must be weighed against the risks of overtreatment., This cohort study examines temporal trends and variations in time-to-antibiotics for sepsis in the US Department of Veterans Affairs health care system., Importance It is unclear whether antimicrobial timing for sepsis has changed outside of performance incentive initiatives. Objective To examine temporal trends and variation in time-to-antibiotics for sepsis in the US Department of Veterans Affairs (VA) health care system. Design, Setting, and Participants This observational cohort study included 130 VA hospitals from 2013 to 2018. Participants included all patients admitted to the hospital via the emergency department with sepsis from 2013 to 2018, using a definition adapted from the Centers for Disease Control and Prevention Adult Sepsis Event definition, which requires evidence of suspected infection, acute organ dysfunction, and systemic antimicrobial therapy within 12 hours of presentation. Data were analyzed from October 6, 2020, to July 1, 2021. Exposures Time from presentation to antibiotic administration. Main Outcomes and Measures The main outcome was differences in time-to-antibiotics across study periods, hospitals, and patient subgroups defined by presenting temperature and blood pressure. Temporal trends in time-to-antibiotics were measured overall and by subgroups. Hospital-level variation in time-to-antibiotics was quantified after adjusting for differences in patient characteristics using multilevel linear regression models. Results A total of 111 385 hospitalizations for sepsis were identified, including 107 547 men (96.6%) men and 3838 women (3.4%) with a median (interquartile range [IQR]) age of 68 (62-77) years. A total of 7574 patients (6.8%) died in the hospital, and 13 855 patients (12.4%) died within 30 days. Median (IQR) time-to-antibiotics was 3.9 (2.4-6.5) hours but differed by presenting characteristics. Unadjusted median (IQR) time-to-antibiotics decreased over time, from 4.5 (2.7-7.1) hours during 2013 to 2014 to 3.5 (2.2-5.9) hours during 2017 to 2018 (P

Rationale & Objective Acute kidney injury treated with kidney replacement therapy (AKI-KRT) occurs frequently in critically ill patients with COVID-19. We examined the clinical factors that determine kidney recovery in this population. Study Design Multicenter cohort study. Setting & Participants 4221 adults with COVID-19 not receiving kidney replacement therapy who were admitted to intensive care units at 68 US hospitals with COVID-19 from March 1 to June 22, 2020 (the “ICU cohort”). Among these, 876 developed AKI-KRT after admission to the ICU (the “AKI-KRT subcohort”). Exposure(s) The ICU cohort was analyzed using AKI severity as the exposure. For the AKI-KRT subcohort, exposures included demographics, comorbidities, initial mode of KRT, and markers of illness severity at the time of dialysis initiation. Outcome(s) The outcome for the ICU cohort was estimated glomerular filtration rate (GFR) at hospital discharge. A three-level outcome including death, kidney nonrecovery, and kidney recovery at discharge, was analyzed for the AKI-KRT subcohort. Analytical approach The ICU cohort was characterized using descriptive analyses. The AKI-KRT subcohort was characterized with both descriptive analyses and multinomial logistic regression to assess factors associated with kidney nonrecovery while accounting for death. Results Among a total of 4221 patients in the ICU cohort, 2361 (56%) developed AKI, including 876 (21%) who received KRT. More severe AKI was associated with higher mortality. Among survivors, more severe AKI was associated with an increased rate of kidney nonrecovery and lower kidney function at discharge. Among the 876 patients with AKI-KRT, 588 (67%) died, 95 (11%) had kidney nonrecovery, and 193 (22%) had kidney recovery by the time of discharge. The odds of kidney nonrecovery was greater for lower estimated GFR with odds ratios (ORs) of 2.09 (95% CI, 1.09-4.04), 4.27 (95% CI, 1.99-9.17), and 8.69 (95% CI, 3.07-24.55) for CKD GFR categories 3, 4, and 5, respectively, compared to estimated GFR > 60 mL/min/1.73 m2. Oliguria at the time of KRT initiation was also associated with nonrecovery (OR 2.10 [95% CI, 1.14-3.88] and 4.02 [95% CI, 1.72-9.39] for patients with 50-499 and, Critically ill patients with COVID-19 often develop acute kidney injury (AKI). This study of 4221 patients demonstrated that more severe AKI was associated with greater in-hospital mortality and poorer kidney function at hospital discharge. Among the 876 patients who required dialysis for AKI, almost two-thirds died. Among those who survived to discharge, about two-thirds recovered kidney function and were discharged without the need for dialysis. Lower baseline kidney function and reduced urine output were associated with non-recovery of kidney function. Identification of such predictors is important in assessing prognosis among these critically ill patients and has implications for clinical care of individuals critically ill with COVID-19.

Supplemental Digital Content is available in the text., OBJECTIVES: Critically ill patients with coronavirus disease 2019 have variable mortality. Risk scores could improve care and be used for prognostic enrichment in trials. We aimed to compare machine learning algorithms and develop a simple tool for predicting 28-day mortality in ICU patients with coronavirus disease 2019. DESIGN: This was an observational study of adult patients with coronavirus disease 2019. The primary outcome was 28-day inhospital mortality. Machine learning models and a simple tool were derived using variables from the first 48 hours of ICU admission and validated externally in independent sites and temporally with more recent admissions. Models were compared with a modified Sequential Organ Failure Assessment score, National Early Warning Score, and CURB-65 using the area under the receiver operating characteristic curve and calibration. SETTING: Sixty-eight U.S. ICUs. PATIENTS: Adults with coronavirus disease 2019 admitted to 68 ICUs in the United States between March 4, 2020, and June 29, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study included 5,075 patients, 1,846 (36.4%) of whom died by day 28. eXtreme Gradient Boosting had the highest area under the receiver operating characteristic curve in external validation (0.81) and was well-calibrated, while k-nearest neighbors were the lowest performing machine learning algorithm (area under the receiver operating characteristic curve 0.69). Findings were similar with temporal validation. The simple tool, which was created using the most important features from the eXtreme Gradient Boosting model, had a significantly higher area under the receiver operating characteristic curve in external validation (0.78) than the Sequential Organ Failure Assessment score (0.69), National Early Warning Score (0.60), and CURB-65 (0.65; p < 0.05 for all comparisons). Age, number of ICU beds, creatinine, lactate, arterial pH, and Pao2/Fio2 ratio were the most important predictors in the eXtreme Gradient Boosting model. CONCLUSIONS: eXtreme Gradient Boosting had the highest discrimination overall, and our simple tool had higher discrimination than a modified Sequential Organ Failure Assessment score, National Early Warning Score, and CURB-65 on external validation. These models could be used to improve triage decisions and clinical trial enrichment.

The 2019 SPE Annual Technical Conference and Exhibition (ATCE) was held in Canada for the first time during 29 September–2 October. More than 6,000 petroleum professionals attended the event in Calgary, which offered a comprehensive review of technical topics related to industry productivity, digital transformation, safety, and sustainability.•• • Industry’s Difficult Task: Meet Global Demand While Lowering Emissions John Donnelly, JPT Editor The oil and gas industry must not only adapt to heightened public and government scrutiny on environmental issues but also be a leader in the world’s quest for a lower-carbon energy future, panelists agreed during the opening session at the conference. The panel session, titled “Positively Impacting the World through Responsible Energy Development,” featured participants from BP, Baker Hughes, Gazprom Neft, and ARC Energy Research•Institute. • Industry Strives To Leave Operations Alone Adam Wilson, Special Publications Editor Having rigs that run without people can increase safety and efficiency. The industry has known that for years, yet implementing these remote operations sometimes has been a challenge, and integrating these operations has been an even larger challenge. That was the topic at a panel dinner held by SPE’s Digital Energy Technical Section during the conference. “Remote has been embedded in the digital concept for over 10 or 15 years,” said Tony Edwards, chief executive officer of Stepchange Global and moderator of the panel. “The idea of taking data information from your operations center, bringing it to the back office, and actually being able to do something is core to the digital oilfield integrated operations concept for 10 or 15 years now.” • Bandwidth of Nanotechnology in the Oil Field Widens Judy Feder, Technology Editor On the final day of the conference, attendees filled a hall to listen to seven experts discuss the value to the oil and gas industry of particles that are less than 1 micron in length. Nanotechnology has great potential to reduce cost, increase production, and even improve the sustainability of E&P operations. The gap between potential and reality is closing, the number of applications is growing, and the industry is ready and willing to use nanotechnology if it can be shown to deliver better performance for less money, according to the panelists and moderators—Steven Bryant of the University of Calgary; Hugh Daigle of The University of Texas at Austin; Ramanan Krishnamoorti of the University of Houston; Oya Karazincir of Chevron; Reinhard Pongratz and Philipp Urban of OMV Exploration; and Hui Zhang of M-I Swaco. Nanotech in oil and gas has become a hammer with many nails. • Women in Energy Share Tips, Tricks, and Wisdom at Inaugural Meeting Judy Feder, Technology Editor The real challenge of attracting and retaining women in the upstream oil and gas industry has nothing to do with gender, said four industry leaders at the inaugural SPE Women in Engineering Committee Breakfast. The four—incoming SPE President Shauna Noonan, director of artificial lift engineering for Occidental Petroleum; Helen Chang, chief engineer for Alberta Energy Regulator; Lils Groenendaal, venture planning transition manager for Shell Exploration & Production; and panel moderator Melanie Popp, director of engineering for geoLOGIC Systems— came together to share their thoughts about personal and professional engagement, empowerment, and success with existing and new SPE members. In the course of the discussion, the panelists agreed that the real challenge of attracting and retaining all talent— not just women—is tied to the industry’s unintentional “brand” among people outside it. • Canadian Startups Shine in Calgary Contest Trent Jacobs, JPT Digital Editor They are among the smallest companies in a business dominated by big ones. Yet, despite their size, technology startups have become central to the upstream industry’s mandate to adopt cost-saving and production-enhancing innovations. As more begin to agree with this idea, the infrastructure that supports the oil and gas startup ecosystem is strengthening. The latest evidence came during the SPE 2019 Annual Technology Conference and Exhibition (ATCE) where a dozen startups were invited to take part in the third annual Energy Startup Competition. The event falls under the broader program that is the ATCE Startup Village. • 2020 SPE President Promises to Focus on Strengthening Organization’s Engineering Core Trent Jacobs, JPT Digital Editor This year’s conference wrapped up with the ceremonial induction of the new 2020 SPE President, Shauna Noonan, who is the director of artificial lift engineering for Occidental Petroleum. Noonan’s ascendance to the organization’s top volunteer position comes after she served on the SPE’s board of directors and authored and coauthored more than 25 technical publications. An SPE member since her time as an engineering student at the University of Alberta, Noonan said it was “surreal” to be assuming the presidency in her home province. The annual conference was held in Calgary for the first time.

OBJECTIVE Cancer and its treatment are known to be important risk factors for sepsis, contributing to an estimated 12% of U.S. sepsis admissions in the 1990s. However, cancer treatment has evolved markedly over the past 2 decades. We sought to examine how cancer-related sepsis differs from non-cancer-related sepsis. DESIGN Observational cohort. SETTING National Readmissions Database (2013-2014), containing all-payer claims for 49% of U.S. POPULATION PATIENTS A total of 1,104,363 sepsis hospitalizations. INTERVENTIONS We identified sepsis hospitalizations in the U.S. National Readmissions Database using explicit codes for severe sepsis, septic shock, or Dombrovskiy criteria (concomitant codes for infection and organ dysfunction). We classified hospitalizations as cancer-related versus non-cancer-related sepsis based on the presence of secondary diagnosis codes for malignancy. We compared characteristics (site of infection and organ dysfunction) and outcomes (in-hospital mortality and 30-d readmissions) of cancer-related versus non-cancer-related sepsis hospitalizations. We also completed subgroup analyses by age, cancer types, and specific cancer diagnoses. MEASUREMENTS AND MAIN RESULTS There were 27,481,517 hospitalizations in National Readmissions Database 2013-2014, of which 1,104,363 (4.0%) were for sepsis and 4,150,998 (15.1%) were cancer related. In-hospital mortality in cancer-related sepsis was 27.9% versus 19.5% in non-cancer-related sepsis. The median count of organ dysfunctions was indistinguishable, but the rate of specific organ dysfunctions differed by small amounts (e.g., hematologic dysfunction 20.1% in cancer-related sepsis vs 16.6% in non-cancer-related sepsis; p < 0.001). Cancer-related sepsis was associated with an adjusted absolute increase in in-hospital mortality ranging from 2.2% to 15.2% compared with non-cancer-related sepsis. The mortality difference was greatest in younger adults and waned with age. Patients (23.2%) discharged from cancer-related sepsis were rehospitalized within 30 days, compared with 20.1% in non-cancer-related sepsis (p < 0.001). CONCLUSIONS In this cohort of over 1 million U.S. sepsis hospitalizations, more than one in five were cancer related. The difference in mortality varies substantially across age spectrum and is greatest in younger adults. Readmissions were more common after cancer-related sepsis.

Interview with 2020 SPE President Shauna Noonan Shauna Noonan will take office as 2020 SPE President during the SPE Annual Technical Conference and Exhibition 30 September–2 October in Calgary. She is the director of artificial lift engineering for Occidental Petroleum Corporation, based in Houston, where she directs the company’s efforts in artificial lift system performance globally. Prior to joining Oxy in late 2015, she worked worldwide on artificial lift projects and technology development at ConocoPhillips and Chevron for more than 22 years. She has authored or coauthored more than 25 technical publications on the subject of artificial lift and is a frequent speaker at industry events. She has been an avid SPE volunteer in many roles since first serving as a student section officer. She served on the SPE International Board of Directors as the Technical Director for Production and Operations from 2012–2015. She has driven the development of industry standards and recommended practices for artificial lift systems while serving as chair for ISO and API committees, and has received industry awards for her contributions to the discipline. Noonan holds a BS degree in petroleum engineering from the University of Alberta. What key issues will you emphasize during your year as president? I want to focus on strengthening five areas for SPE to remain a trusted, unbiased source of technical information, be the membership of choice for professionals in oil and gas, and to be respected both within and outside of our industry. When people see that SPE logo, it should be synonymous with excellence in terms of all our offerings to our membership. The theme of my presidency is “SPE strong,” strengthening the core of our society. The five areas are: - Strengthening the technical quality of our publications, presentations, and events - Strengthening the tools and methods by which we disseminate knowledge to our members - Strengthening our core functions, with an additional focus on automation and digital science - Strengthening knowledge transfer in unconventional resources - Strengthening the feedstock of incoming talent into the industry. How will you go about strengthening these areas? For the past year in my role as incoming president, I have been working with my fellow board members and SPE staff to develop the various initiatives around my five focus areas. I will share those details in each of my monthly JPT columns along with updates on our progress. In the latest SPE Strategic Plan, there is an emphasis on instilling professional pride. What should be the focus? I am proud to be a petroleum engineer but I, like many of our members, have not been adept at explaining what exactly our industry does. We need to learn how to have an effective conversation with those outside of our industry on how we lift the world out of poverty and improve the quality of life by providing affordable, sustainable energy while targeting carbon neutrality. An effective conversation is an open dialogue, not a PowerPoint presentation or a factual document.

Rationale: “Target trial emulation” has been proposed as an observational method to answer comparative effectiveness questions, but it has rarely been attempted concurrently with a randomized clinical trial (RCT). Objectives: We tested the hypothesis that blinded analysts applying target trial emulation to existing observational data could predict the results of an RCT. Methods: PreVent (Preventing Hypoxemia with Manual Ventilation during Endotracheal Intubation) was a multicenter RCT examining the effects of positive-pressure ventilation during tracheal intubation on oxygen saturation and severe hypoxemia. Analysts unaware of PreVent’s results used patient-level data from three previous trials evaluating airway management interventions to emulate PreVent’s eligibility criteria, randomization procedure, and statistical analysis. After PreVent’s release, results of this blinded observational analysis were compared with those of the RCT. Difference-in-differences estimates for comparison of treatment effects between the observational analysis and the PreVent trial are reported on the absolute scale. Results: Using observational data, we were able to emulate PreVent’s randomization procedure to produce balanced groups for comparison. The lowest oxygen saturation during intubation was higher in the positive-pressure ventilation group than the no positive-pressure ventilation group in the observational analysis (n = 360; mean difference = 1.8%; 95% confidence interval [CI] = −1.0 to 4.6) and in the PreVent trial (n = 401; mean difference = 3.9%; 95% CI = 1.4 to 6.4), though the observational analysis could not exclude no difference. Difference-in-differences estimates comparing treatment effects showed reasonable agreement for lowest oxygen saturation between the observational analysis and the PreVent trial (mean difference = −2.1%; 95% CI = −5.9 to 1.7). Positive-pressure ventilation resulted in lower rates of severe hypoxemia in both the observational analysis (risk ratio = 0.60; 95% CI = 0.38 to 0.93) and in the PreVent trial (risk ratio = 0.48; 95% CI = 0.30 to 0.77). The absolute reduction in the incidence of severe hypoxemia with positive-pressure ventilation was similar in the observational analysis (9.4%) and the PreVent trial (12.0%), though the difference between these estimates had wide CIs (mean difference = 2.5%; 95% CI = −8.0 to 13.6%). Conclusions: Applying target trial emulation methods to existing observational data for the evaluation of a novel intervention produced results similar to those of a randomized trial. These findings support the use of target trial emulation for comparative effectiveness research.

Study objective The transfusion of older packed RBCs may be harmful in critically ill patients. We seek to determine the association between packed RBC age and mortality among trauma patients requiring massive packed RBC transfusion. Methods We analyzed data from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial. Subjects in the parent trial included critically injured adult patients admitted to 1 of 12 North American Level I trauma centers who received at least 1 unit of packed RBCs and were predicted to require massive blood transfusion. The primary exposure was volume of packed RBC units transfused during the first 24 hours of hospitalization, stratified by packed RBC age category: 0 to 7 days, 8 to 14 days, 15 to 21 days, and greater than or equal to 22 days. The primary outcome was 24-hour mortality. We evaluated the association between transfused volume of each packed RBC age category and 24-hour survival, using random-effects logistic regression, adjusting for total packed RBC volume, patient age, sex, race, mechanism of injury, Injury Severity Score, Revised Trauma Score, clinical site, and trial treatment group. Results The 678 patients included in the analysis received a total of 8,830 packed RBC units. One hundred patients (14.8%) died within the first 24 hours. On multivariable analysis, the number of packed RBCs greater than or equal to 22 days old was independently associated with increased 24-hour mortality (adjusted odds ratio [OR] 1.05 per packed RBC unit; 95% confidence interval [CI] 1.01 to 1.08): OR 0.97 for 0 to 7 days old (95% CI 0.88 to 1.08), OR 1.04 for 8 to 14 days old (95% CI 0.99 to 1.09), and OR 1.02 for 15 to 21 days old (95% CI 0.98 to 1.06). Results of sensitivity analyses were similar only among patients who received greater than or equal to 10 packed RBC units. Conclusion Increasing quantities of older packed RBCs are associated with increased likelihood of 24-hour mortality in trauma patients receiving massive packed RBC transfusion (≥10 units), but not in those who receive fewer than 10 units.

IMPORTANCE: Some experts have cautioned that national and health system emphasis on rapid administration of antimicrobials for sepsis may increase overall antimicrobial use even among patients without sepsis. OBJECTIVE: To assess whether temporal changes in antimicrobial timing for sepsis are associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among all hospitalized patients at risk for sepsis. DESIGN, SETTING, AND PARTICIPANTS: This is an observational cohort study of hospitalized patients at 152 hospitals in 2 health care systems during 2013 to 2018, admitted via the emergency department with 2 or more systemic inflammatory response syndrome (SIRS) criteria. Data analysis was performed from June 10, 2021, to March 22, 2022. EXPOSURES: Hospital-level temporal trends in time to first antimicrobial administration. OUTCOMES: Antimicrobial outcomes included antimicrobial use, days of therapy, and broadness of antibacterial coverage. Clinical outcomes included in-hospital mortality, 30-day mortality, length of hospitalization, and new multidrug-resistant (MDR) organism culture positivity. RESULTS: Among 1 559 523 patients admitted to the hospital via the emergency department with 2 or more SIRS criteria (1 269 998 male patients [81.4%]; median [IQR] age, 67 [59-77] years), 273 255 (17.5%) met objective criteria for sepsis. In multivariable models adjusted for patient characteristics, the adjusted median (IQR) time to first antimicrobial administration to patients with sepsis decreased by 37 minutes, from 4.7 (4.1-5.3) hours in 2013 to 3.9 (3.6-4.4) hours in 2018, although the slope of decrease varied across hospitals. During the same period, antimicrobial use within 48 hours, days of antimicrobial therapy, and receipt of broad-spectrum coverage decreased among the broader cohort of patients with SIRS. In-hospital mortality, 30-day mortality, length of hospitalization, new MDR culture positivity, and new MDR blood culture positivity decreased over the study period among both patients with sepsis and those with SIRS. When examining hospital-specific trends, decreases in antimicrobial use, days of therapy, and broadness of antibacterial coverage for patients with SIRS did not differ by hospital antimicrobial timing trend for sepsis. Overall, there was no evidence that accelerating antimicrobial timing for sepsis was associated with increasing antimicrobial use or impaired antimicrobial stewardship. CONCLUSIONS AND RELEVANCE: In this multihospital cohort study, the time to first antimicrobial for sepsis decreased over time, but this trend was not associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among the broader population at-risk for sepsis, which suggests that shortening the time to antibiotics for sepsis is feasible without leading to indiscriminate antimicrobial use.

Importance The Epic Sepsis Model (ESM), a proprietary sepsis prediction model, is implemented at hundreds of US hospitals. The ESM’s ability to identify patients with sepsis has not been adequately evaluated despite widespread use. Objective To externally validate the ESM in the prediction of sepsis and evaluate its potential clinical value compared with usual care. Design, Setting, and Participants This retrospective cohort study was conducted among 27 697 patients aged 18 years or older admitted to Michigan Medicine, the academic health system of the University of Michigan, Ann Arbor, with 38 455 hospitalizations between December 6, 2018, and October 20, 2019. Exposure The ESM score, calculated every 15 minutes. Main Outcomes and Measures Sepsis, as defined by a composite of (1) the Centers for Disease Control and Prevention surveillance criteria and (2)International Statistical Classification of Diseases and Related Health Problems, Tenth Revisiondiagnostic codes accompanied by 2 systemic inflammatory response syndrome criteria and 1 organ dysfunction criterion within 6 hours of one another. Model discrimination was assessed using the area under the receiver operating characteristic curve at the hospitalization level and with prediction horizons of 4, 8, 12, and 24 hours. Model calibration was evaluated with calibration plots. The potential clinical benefit associated with the ESM was assessed by evaluating the added benefit of the ESM score compared with contemporary clinical practice (based on timely administration of antibiotics). Alert fatigue was evaluated by comparing the clinical value of different alerting strategies. Results We identified 27 697 patients who had 38 455 hospitalizations (21 904 women [57%]; median age, 56 years [interquartile range, 35-69 years]) meeting inclusion criteria, of whom sepsis occurred in 2552 (7%). The ESM had a hospitalization-level area under the receiver operating characteristic curve of 0.63 (95% CI, 0.62-0.64). The ESM identified 183 of 2552 patients with sepsis (7%) who did not receive timely administration of antibiotics, highlighting the low sensitivity of the ESM in comparison with contemporary clinical practice. The ESM also did not identify 1709 patients with sepsis (67%) despite generating alerts for an ESM score of 6 or higher for 6971 of all 38 455 hospitalized patients (18%), thus creating a large burden of alert fatigue. Conclusions and Relevance This external validation cohort study suggests that the ESM has poor discrimination and calibration in predicting the onset of sepsis. The widespread adoption of the ESM despite its poor performance raises fundamental concerns about sepsis management on a national level.

Variation in hospital mortality has been described for coronavirus disease 2019 (COVID-19), but the factors that explain these differences remain unclear.Our objective was to utilize a large, nationally representative dataset of critically ill adults with COVID-19 to determine which factors explain mortality variability.In this multicenter cohort study, we examined adults hospitalized in intensive care units with COVID-19 at 70 United States hospitals between March and June 2020. The primary outcome was 28-day mortality. We examined patient-level and hospital-level variables. Mixed-effects logistic regression was used to identify factors associated with interhospital variation. The median odds ratio (OR) was calculated to compare outcomes in higher- vs. lower-mortality hospitals. A gradient boosted machine algorithm was developed for individual-level mortality models.A total of 4,019 patients were included, 1537 (38%) of whom died by 28 days. Mortality varied considerably across hospitals (0-82%). After adjustment for patient- and hospital-level domains, interhospital variation was attenuated (OR decline from 2.06 [95% CI, 1.73-2.37] to 1.22 [95% CI, 1.00-1.38]), with the greatest changes occurring with adjustment for acute physiology, socioeconomic status, and strain. For individual patients, the relative contribution of each domain to mortality risk was: acute physiology (49%), demographics and comorbidities (20%), socioeconomic status (12%), strain (9%), hospital quality (8%), and treatments (3%).There is considerable interhospital variation in mortality for critically ill patients with COVID-19, which is mostly explained by hospital-level socioeconomic status, strain, and acute physiologic differences. Individual mortality is driven mostly by patient-level factors. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Summary: Many US states published crisis standards of care (CSC) guidelines for allocating scarce critical care resources during the COVID-19 pandemic. However, the performance of these guidelines in maximizing their population benefit has not been well tested. In 2,272 adults with COVID-19 requiring mechanical ventilation drawn from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID) multicenter cohort, we test the following three approaches to CSC algorithms: Sequential Organ Failure Assessment (SOFA) scores grouped into ranges, SOFA score ranges plus comorbidities, and a hypothetical approach using raw SOFA scores not grouped into ranges. We find that area under receiver operating characteristic (AUROC) curves for all three algorithms demonstrate only modest discrimination for 28-day mortality. Adding comorbidity scoring modestly improves algorithm performance over SOFA scores alone. The algorithm incorporating comorbidities has modestly worse predictive performance for Black compared to white patients. CSC algorithms should be empirically examined to refine approaches to the allocation of scarce resources during pandemics and to avoid potential exacerbation of racial inequities.

Rationale & Objective Underlying kidney disease is an emerging risk factor for more severe COVID-19 illness. We examined the clinical courses of critically ill COVID-19 patients with and without pre-existing kidney disease and investigated the association between degree of underlying kidney disease and in-hospital outcomes. Study Design Retrospective cohort study Settings & Participants 4,264 critically ill COVID-19 patients (143 dialysis patients, 521 chronic kidney disease [CKD] patients, and 3,600 patients without CKD) admitted to ICUs at 68 hospitals in the United States. Predictor(s) Presence (versus absence) of pre-existing kidney disease Outcome(s) In-hospital mortality (primary); respiratory failure, shock, ventricular arrhythmia/ cardiac arrest, thromboembolic event, major bleed, and acute liver injury (secondary) Analytical Approach We used standardized differences to compare patient characteristics (values >0.10 indicate a meaningful difference between groups) and multivariable adjusted Fine and Gray survival models to examine outcome associations. Results Dialysis patients had a shorter time from symptom onset to ICU admission compared to other groups (median [quartile 1-quartile 3] days: 4 [2-9] for dialysis patients; 7 [3-10] for CKD patients; 7 [4-10] for patients without pre-existing kidney disease). More dialysis patients (25%) reported altered mental status than those with CKD (20%, standardized difference = 0.12) and no kidney disease (12%, standardized difference = 0.36). Half of dialysis and CKD patients died within 28-days of ICU admission versus 35% of patients without pre-existing kidney disease. Compared to patients without pre-existing kidney disease, dialysis patients had a higher risk of 28-day in-hospital death (adjusted HR 1.41; 95% CI 1.09, 1.81), while patients with CKD had an intermediate risk (adjusted HR 1.25; 95% CI 1.08, 1.44). Limitations Potential residual confounding Conclusions Findings highlight the high mortality of individuals with underlying kidney disease and severe COVID-19, underscoring the importance of identifying safe and effective COVID-19 therapies for this vulnerable population., Individuals with underlying kidney disease may be particularly vulnerable to severe COVID-19 illness, marked by multi-system organ failure, thrombosis, and a heightened inflammatory response. Among 4,264 critically ill adults with COVID-19 admitted to 68 intensive care units across the U.S., we found that both chronic kidney disease and dialysis patients had a ∼50% 28-day in-hospital mortality rate. Patients with underlying kidney disease had higher in-hospital mortality than patients without kidney disease, with patients on maintenance dialysis having the highest risk. As evidenced by differences in symptoms and clinical trajectories, patients with pre-existing kidney disease may have unique susceptibility to COVID-19-related complications which warrants additional study and special consideration in the pursuit and development of targeted therapies.

Hypercoagulability may be a key mechanism of death in patients with COVID-19. This cohort study evaluated the incidence of venous thromboembolism and major bleeding in critically ill patients with COVID-19 and examined the observational effect of early therapeutic anticoagulation on survival., Visual Abstract. Early Anticoagulation in COVID-19 Hypercoagulability may be a key mechanism of death in patients with COVID-19. This cohort study evaluated the incidence of venous thromboembolism and major bleeding in critically ill patients with COVID-19 and examined the observational effect of early therapeutic anticoagulation on survival. Visual Abstract. Early Anticoagulation in COVID-19 Hypercoagulability may be a key mechanism of death in patients with COVID-19. This cohort study evaluated the incidence of venous thromboembolism and major bleeding in critically ill patients with COVID-19 and examined the observational effect of early therapeutic anticoagulation on survival., Background: Hypercoagulability may be a key mechanism of death in patients with coronavirus disease 2019 (COVID-19). Objective: To evaluate the incidence of venous thromboembolism (VTE) and major bleeding in critically ill patients with COVID-19 and examine the observational effect of early therapeutic anticoagulation on survival. Design: In a multicenter cohort study of 3239 critically ill adults with COVID-19, the incidence of VTE and major bleeding within 14 days after intensive care unit (ICU) admission was evaluated. A target trial emulation in which patients were categorized according to receipt or no receipt of therapeutic anticoagulation in the first 2 days of ICU admission was done to examine the observational effect of early therapeutic anticoagulation on survival. A Cox model with inverse probability weighting to adjust for confounding was used. Setting: 67 hospitals in the United States. Participants: Adults with COVID-19 admitted to a participating ICU. Measurements: Time to death, censored at hospital discharge, or date of last follow-up. Results: Among the 3239 patients included, the median age was 61 years (interquartile range, 53 to 71 years), and 2088 (64.5%) were men. A total of 204 patients (6.3%) developed VTE, and 90 patients (2.8%) developed a major bleeding event. Independent predictors of VTE were male sex and higher D-dimer level on ICU admission. Among the 2809 patients included in the target trial emulation, 384 (11.9%) received early therapeutic anticoagulation. In the primary analysis, during a median follow-up of 27 days, patients who received early therapeutic anticoagulation had a similar risk for death as those who did not (hazard ratio, 1.12 [95% CI, 0.92 to 1.35]). Limitation: Observational design. Conclusion: Among critically ill adults with COVID-19, early therapeutic anticoagulation did not affect survival in the target trial emulation. Primary Funding Source: None.

This study describes reasons for readmission, use of ICU interventions during readmission, and proportions of death after initial hospital discharge of COVID-19 patients from US Veterans Affairs (VA) hospitals in March-June 2020.

IntroductionThe Epic Deterioration Index (EDI) is a proprietary prediction model implemented in over 100 U.S. hospitals that was widely used to support medical decision-making during the COVID-19 pandemic. The EDI has not been independently evaluated, and other proprietary models have been shown to be biased against vulnerable populations.MethodsWe studied adult patients admitted with COVID-19 to non-ICU care at a large academic medical center from March 9 through May 20, 2020. We used the EDI, calculated at 15-minute intervals, to predict a composite outcome of ICU-level care, mechanical ventilation, or in-hospital death. In a subset of patients hospitalized for at least 48 hours, we also evaluated the ability of the EDI to identify patients at low risk of experiencing this composite outcome during their remaining hospitalization.ResultsAmong 392 COVID-19 hospitalizations meeting inclusion criteria, 103 (26%) met the composite outcome. Median age of the cohort was 64 (IQR 53-75) with 168 (43%) African Americans and 169 (43%) women. Area under the receiver-operating-characteristic curve (AUC) of the EDI was 0.79 (95% CI 0.74-0.84). EDI predictions did not differ by race or sex. When exploring clinically-relevant thresholds of the EDI, we found patients who met or exceeded an EDI of 68.8 made up 14% of the study cohort and had a 74% probability of experiencing the composite outcome during their hospitalization with a median lead time of 24 hours from when this threshold was first exceeded. Among the 286 patients hospitalized for at least 48 hours who had not experienced the composite outcome, 14 (13%) never exceeded an EDI of 37.9, with a negative predictive value of 90% and a sensitivity above this threshold of 91%.ConclusionWe found the EDI identifies small subsets of high- and low-risk COVID-19 patients with fair discrimination. We did not find evidence of bias by race or sex. These findings highlight the importance of independent evaluation of proprietary models before widespread operational use among COVID-19 patients.

Background Claims-based algorithms are commonly used to identify sepsis in health services research because the laboratory features required to define clinical criteria may not be available in administrative data. Methods We evaluated claims-based sepsis algorithms among adults in the US aged ≥65 years with Medicare health insurance enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Suspected infections from baseline (2003–2007) through December 31, 2012 were analyzed. Two claims-based algorithms were evaluated: (1) infection plus organ dysfunction diagnoses or sepsis diagnoses (Medicare-Implicit/Explicit) and (2) Centers for Medicare and Medicaid Services Severe Sepsis/Septic Shock Measure diagnoses (Medicare-CMS). Three classifications based on clinical criteria were used as standards for comparison: (1) the sepsis-related organ failure assessment (SOFA) score (REGARDS-SOFA), (2) “quick” SOFA (REGARDS-qSOFA), and (3) Centers for Disease Control and Prevention electronic health record criteria (REGARDS-EHR). Results There were 2217 suspected infections among 9522 participants included in the current study. The total number of suspected infections classified as sepsis was 468 for Medicare-Implicit/Explicit, 249 for Medicare-CMS, 541 for REGARDS-SOFA, 185 for REGARDS-qSOFA, and 331 for REGARDS-EHR. The overall agreement between Medicare-Implicit/Explicit and REGARDS-SOFA, REGARDS-qSOFA, and REGARDS-EHR was 77, 79, and 81%, respectively, sensitivity was 46, 53, and 57%, and specificity was 87, 82, and 85%. Comparing Medicare-CMS and REGARDS-SOFA, REGARDS-qSOFA, and REGARDS-EHR, agreement was 77, 87, and 85%, respectively, sensitivity was 27, 41, and 36%, and specificity was 94, 92, and 93%. Events meeting the REGARDS-SOFA classification had a lower 90-day mortality rate (140.7 per 100 person-years) compared with the Medicare-CMS (296.1 per 100 person-years), REGARDS-qSOFA (238.6 per 100 person-years), Medicare-Implicit/Explicit (219.4 per 100 person-years), and REGARDS-EHR classifications (201.8 per 100 person-years). Conclusion Claims-based sepsis algorithms have high agreement and specificity but low sensitivity when compared with clinical criteria. Both claims-based algorithms identified a patient population with similar 90-day mortality rates as compared with classifications based on qSOFA and EHR criteria but higher mortality relative to SOFA criteria.

OBJECTIVES Severe sepsis is a significant cause of healthcare utilization and morbidity among pediatric patients. However, little is known about how commonly survivors acquire new medical devices during pediatric severe sepsis hospitalization. We sought to determine the rate of new device acquisition (specifically, tracheostomy placement, gastrostomy tube placement, vascular access devices, ostomy procedures, and amputation) among children surviving hospitalizations with severe sepsis. For contextualization, we compare this to rates of new device acquisition among three comparison cohorts: 1) survivors of all-cause pediatric hospitalizations; 2) matched survivors of nonsepsis infection hospitalizations; and 3) matched survivors of all-cause nonsepsis hospitalization with similar organ dysfunction. DESIGN Observational cohort study. SETTING Nationwide Readmission Database (2016), including all-payer hospitalizations from 27 states. PATIENTS Eighteen-thousand two-hundred ten pediatric severe sepsis hospitalizations; 532,738 all-cause pediatric hospitalizations; 16,173 age- and sex-matched nonsepsis infection hospitalizations; 15,025 organ dysfunction matched all-cause nonsepsis hospitalizations; and all with live discharge. MEASUREMENTS AND MAIN RESULTS Among 18,210 pediatric severe sepsis hospitalizations, 1,024 (5.6%) underwent device placement. Specifically, 3.5% had new gastrostomy, 3.1% new tracheostomy, 0.6% new vascular access devices, 0.4% new ostomy procedures, and 0.1% amputations. One-hundred forty hospitalizations (0.8%) included two or more new devices. After applying the Nationwide Readmissions Database sampling weights, there were 55,624 pediatric severe sepsis hospitalizations and 1,585,194 all-cause nonsepsis hospitalizations with live discharge in 2016. Compared to all-cause pediatric hospitalizations, severe sepsis hospitalizations were eight-fold more likely to involve new device acquisition (6.4% vs 0.8%; p < 0.001). New device acquisition was also higher in severe sepsis hospitalizations compared with matched nonsepsis infection hospitalizations (5.1% vs 1.2%; p < 0.01) and matched all-cause hospitalizations with similar organ dysfunction (4.7% vs 2.8%; p < 0.001). CONCLUSIONS In this nationwide, all-payer cohort of U.S. pediatric severe sepsis hospitalizations, one in 20 children surviving severe sepsis experienced new device acquisition. The procedure rate was nearly eight-fold higher than all-cause, nonsepsis pediatric hospitalizations, and four-fold higher than matched nonsepsis infection hospitalizations.

Introduction: We previously reported that age and race disparities exist in transfer for a higher level of care among acute ischemic stroke (AIS) patients. This study examined the association of transfer with in-hospital mortality stratified by age and race. Methods: In this cross-sectional analysis, we extracted AIS patient characteristics and transfer status from State Emergency Department Databases and State Inpatient Databases of 7 states between 1/1/2010-12/29/2010. We used stabilized inverse probability of treatment weights and fit generalized linear models with a flexible restricted cubic spline term for age, reporting risk differences (RDs) and risk ratios (RRs) with 95% confidence intervals (CIs). Because of potential unmeasured confounders, we reported E-values, which represent the minimum confounder-outcome and exposure-confounder RRs that could shift the associations to the null or the CI limits to include 1. Results: We identified 82,487 AIS discharges of whom 5.4% were transferred. After adjusting for age, race, gender, hospital type, minority-serving status, and Elixhauser comorbidities through weighting, transferred white patients, particularly age 2.0), but a weaker confounder could shift the CIs (RRs>1.5). The NIHSS has been reported to have E-values as high as 1.8. Conclusions: In our geographically diverse sample, we found that AIS transfer is associated with higher in-hospital mortality among white patients and younger black patients. Our data suggests that a strong unmeasured confounder could explain the association. Further work is needed to identify factors leading to higher mortality in transferred AIS patients.

Introduction Racial disparities in heart failure hospitalizations are well documented. The majority of heart failure hospitalizations originate from emergency departments, but emergency department hospitalization patterns for heart failure and the factors that influence hospitalization are poorly understood. This gap in knowledge was examined using a nationally representative sample of emergency department visits for heart failure. Methods National Hospital Ambulatory Medicare Care Survey data on 2001–2010 emergency department visits were analyzed in 2015–2017 to examine age-related racial differences in hospitalization patterns for heart failure, using multivariable modified Poisson regression models. Results More than 12million adult visits for heart failure to U.S. emergency departments occurred from 2001 to 2010, with 23% of visits by blacks. Overall, 71% of visits resulted in hospitalization (57% to floor beds and 14% to intensive care units). Among floor admissions for higher clinical acuity visits, whites were more likely than blacks to be hospitalized. Whites with higher clinical acuity were more likely to be hospitalized than those with lower clinical acuity (71% vs 63%, p=0.005). This expected pattern was not observed in blacks, particularly those aged ≥65years, who were hospitalized in 71% of lower clinical acuity visits, but only 61% of higher acuity visits. Among adults aged ≥65years, there was a significant interaction between clinical acuity Xrace with regard to hospitalization (p=0.037). Conclusions These results suggest age and racial disparities in hospitalization rates for emergency department patients with heart failure. The reasons for these disparities in hospitalization are unclear. Further studies on emergency department hospitalization decisions, and the impact of emergency department clinical factors, may help clarify this finding. Supplement information This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Sepsis – syndrome of infection complicated by organ dysfunction – is responsible for over 750 000 hospitalisations and 200 000 deaths in the USA annually. Despite potential nutritional benefits, the association of diet and sepsis is unknown. Therefore, we sought to determine the association between adherence to a Mediterranean-style diet (Med-style diet) and long-term risk of sepsis in the REasons for Geographic Differences in Stroke (REGARDS) cohort. We analysed data from REGARDS, a population-based cohort of 30 239 community-dwelling adults age ≥45 years. We determined dietary patterns from a baseline FFQ. We defined Med-style diet as a high consumption of fruit, vegetables, legumes, fish, cereal and low consumption of meat, dairy products, fat and alcohol categorising participants into Med-style diet tertiles (low: 0–3, moderate: 4–5, high: 6–9). We defined sepsis events as hospital admission for serious infection and at least two systematic inflammatory response syndrome criteria. We used Cox proportional hazard models to determine the association between Med-style diet tertiles and first sepsis events, adjusting for socio-demographics, lifestyle factors, and co-morbidities. We included 21 256 participants with complete dietary data. Dietary patterns were: low Med-style diet 32·0 %, moderate Med-style diet 42·1 % and high Med-style diet 26·0 %. There were 1109 (5·2 %) first sepsis events. High Med-style diet was independently associated with sepsis risk; low Med-style diet referent, moderate Med-style diet adjusted hazard ratio (HR) 0·93 (95 % CI 0·81, 1·08), high Med-style diet adjusted HR=0·74 (95 % CI 0·61, 0·88). High Med-style diet adherence is associated with lower risk of sepsis. Dietary modification may potentially provide an option for reducing sepsis risk.

Conference review The offshore oil and gas sector is beginning to recover 2 years after oil prices bottomed out, which has led to cautious optimism in the sector. At this year’s Offshore Technology Conference, held 30 April–3 May in Houston, that feeling was evident, although there is still a strong emphasis on cost containment and efficiency. This year was the 50th OTC, which has become a bellwether for the health of the offshore industry. Panel sessions, individual talks, and technical sessions focused on a range of topics, including the current state of the industry, reducing costs, breakthrough technologies in a low-oil-price environment, and the growing use of data analytics and digital technologies. More than 61,300 attendees from more than 100 countries gathered at the annual conference. Below are selected highlights from the conference. Offshore Retrospective The 50th edition of OTC kicked off with a distinguished panel representing operators and service companies evaluating the contributions of the past half century. And while the panel took a look back at the significant progress and innovation that has occurred since 1969, they also painted an optimistic view of the offshore sector’s future. The opening ceremony featured remarks from Wafik Beydoun, chairman of the OTC Board of Directors, and panelists Patrick Pouyanné, chairman and CEO, Total; Ryan Lance, chairman and CEO, ConocoPhillips; Jeff Miller, president and CEO, Halliburton; Harry Brekelmans, project and technology director, Royal Dutch Shell; Clay Williams, chairman and CEO, National Oilwell Varco (NOV); and Solange da Silva Guedes, chief exploration and production officer, Petrobras. Speakers emphasized the progress made in the safety of offshore operations as well as the technological innovation that has occurred since the first OTC was held in a small convention hall in Houston that attracted 2,800 attendees. More than 60,000 industry professionals attended last year’s conference. After listing some of his company’s significant offshore developments over the years in Abu Dhabi, Africa, and the North Sea, Total’s Pouyanné expressed optimism about the offshore sector’s continued health, noting that many legacy discoveries are still producing or have led to new ones. “The past also affects the future,” he said. Oil price cycles and technical challenges will continue to be managed. “In our industry, anything is possible and nothing is impossible,” he added. “What makes me very confident for the future of offshore and the deep water industry is its capacity to innovate.” Lance, noting emergence of unconventional onshore output, said offshore projects in the future have to work at the lower end of the oil price boundary. Projects need improved design and efficiency as well as standardization. “Design one, and build many” should be the watchword going forward, he said. The use of data analytics, machine learning, and blockchain all have potential to make the offshore sector more efficient and economic, he added.

E&P Notes Alternatives No Threat to Oil, Aramco CEO Says John Donnelly, JPT Editor Alternative energy options and worries about climate change are not a threat to the oil and gas industry, which will need increased investment just to keep up with future demand, said the chief executive officer of Saudi Aramco. The idea that alternatives to hydrocarbons such as electric vehicles will displace oil and gas in the global fuel mix any time soon is a gross oversimplification, Amin Nasser, the head of Saudi Aramco, said during the annual CERAWeek conference by IHS Markit, which took place last month in Houston. “I am not losing any sleep over the idea of peak oil demand or stranded resources,” he said. IEA Sees No End to US Shale Output Surge Matt Zborowski, Technology Writer US crude production is projected to surge to 12.1 million B/D by 2023 amid “a second wave” of shale output increases, making the country the world’s largest oil producer, according to the International Energy Agency’s latest 5-year market forecast. The new wave is underpinned by higher oil prices following the pact between OPEC producers and a group of non-OPEC countries to collectively curb out-put through this year. “Everyone has benefited” from the deal, and newfound optimism has spread through the industry, said OPEC Secretary General Mohammed Barkindo during the CERAWeek conference by IHS Markit in Houston. ExxonMobil Exits Russian Ventures, Continues Success off Guyana Matt Zborowski, Technology Writer ExxonMobil marked a continued companywide transition for the world’s largest public oil and gas firm, headlined by its withdrawal from once-promising Russian joint ventures (JVs) and its announcement of a seventh oil discovery off Guyana. According to a filing with the US Securities and Exchange Commission, ExxonMobil is pulling out of its JVs with Rosneft, established earlier this decade, that involved exploration and development of Arctic, Black Sea, and shale resources. ExxonMobil’s role in those partner-ships was quashed when the US government levied sanctions on Russia in 2014 following its annexation of Crimea and expanded those measures in late 2017. ExxonMobil sued the US Department of the Treasury last year in response to a $2-million fine for violating the 2014 sanctions. BP: Robust Adoption of Electric Vehicles Would Not Stop Oil Consumption Growth Joel Parshall, JPT Features Editor Even a robust adoption of electric vehicles (EVs) over the next 2 decades would not eliminate the growth of either global oil consumption or carbon emissions, BP Chief Economist Spencer Dale said in February as the company introduced its 2018 Energy Outlook. And to meet the goals of the Paris Climate Accord, Dale said, the outlook concludes that a system of global carbon emission pricing and increased regulation to spur energy efficiency and fuel switching would probably be needed in addition to EV adoption. Projecting the future impact of EVs on oil consumption and emissions involves more than counting the number of them and their percentage share in the global vehicle fleet, he said. Another Big Gas Field Starts Production Offshore Egypt Matt Zborowski, Technology Writer The Atoll Phase One project in the East Nile Delta is flowing 350 MMcf/D of gas and 10,000 B/D of condensate to shore after starting up “7 months ahead of schedule and 33% below the initial cost estimate,” operator BP reported. The $1-billion project in the North Damietta concession provides another heavy stream of gas for domestic use in Egypt following the 2017 production launches of the Eni-operated supergiant Zohr field and the BP-operated Taurus and Libra fields of the West Nile Delta development. BP has a 10% stake in the Shorouk concession containing Zohr, which is expected to flow 1 Bcf/D by mid-year. The British supermajor operates the West Nile Delta project with an 82.75% interest in the project partnership.

Background Prior studies suggest disparities in sepsis risk and outcomes based on place of residence. We sought to examine the association between neighborhood socioeconomic status (nSES) and hospitalization for infection and sepsis. Methods We conducted a prospective cohort study using data from 30239 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. nSES was defined using a score derived from census data and classified into quartiles. Infection and sepsis hospitalizations were identified over the period 2003-2012. We fit Cox proportional hazards models, reporting hazard ratios (HRs) with 95% confidence intervals (CIs) and examining mediation by participant characteristics. Results Over a median follow-up of 6.5 years, there were 3054 hospitalizations for serious infection. Infection incidence was lower for participants in the highest nSES quartile compared with the lowest quartile (11.7 vs 15.6 per 1000 person-years). After adjustment for demographics, comorbidities, and functional status, infection hazards were also lower for the highest quartile (HR, 0.84 [95% CI, .73-.97]), with a linear trend (P = .011). However, there was no association between nSES and sepsis at presentation among those hospitalized with infection. Physical weakness, income, and diabetes had modest mediating effects on the association of nSES with infection. Conclusions Our study shows that differential infection risk may explain nSES disparities in sepsis incidence, as higher nSES is associated with lower infection hospitalization rates, but there is no association with sepsis among those hospitalized. Mediation analysis showed that nSES may influence infection hospitalization risk at least partially through physical weakness, individual income, and comorbid diabetes.

2019 OTC review Digitalization and automation were key topics in the panel and technical sessions at this year’s Offshore Technology Conference (OTC) as the iconic event celebrated its 50th anniversary. More than 59,000 attendees participated in the conference, which was held 6–9 May in Houston. OTC launched its golden anniversary with a wide-ranging panel discussion on the current viability of the offshore sector and how digitalization will change it in the future. Total’s Energy Outlook 2040 proposes two distinct scenarios of the energy future: a momentum scenario, in which oil demand is dominated by transportation and petrochemicals, and a rupture scenario, which sees a massive shift in public policy and the growth of renewables. Either way, “our industry has a major role to play in climate change issues,” said Arnaud Breuillac, president of exploration and production for Total. The global energy mix is changing, he said, but the question is how rapidly, especially regarding use of electric vehicles and the growth of electrification in developing countries. Given the projected population rise and the fact that 1.5 billion people do not have access to energy now, increased use of natural gas and renewables is the “right approach to stabilize the energy system,” Breuillac said. The 21st century will likely be the “century of electricity,” he added. “It is clear that the pace of change does not lie entirely in our hands,” he said about the use of hydrocarbons in the future, but will be influenced by the public and policymakers as well. For now, Total is pursuing projects on the low end of the cost curve while trying to reduce its carbon footprint from production to customer delivery. Whether the industry should pursue a future of reduced hydrocarbon production and use appears to be a dilemma, said panel moderator Scott Tinker, director of the Bureau of Economic Geology at The University of Texas at Austin. If climate change is the worst problem, then reduced hydrocarbon use could be part of the solution; but if poverty is the globe’s biggest issue, then hydrocarbons are undoubtedly part of the solution. Although the industry “does produce a lot of CO2,” Tinker said, access to readily available and affordable energy also alleviates hunger and provides clothing, shelter, and clean water, and allows access to education, health care, and medical services, among other things. Offering more perspective, Tinker noted that although there is a lot of talk about the growth in wind and power for energy, their use is but a fraction of demand for oil, natural gas, and coal. Over the past several decades, carbon emissions in the US and Europe have been flat to slightly down, while emissions in Asia have grown sharply, he said.

More than 8,300 professionals from 60 countries attended the 2017 SPE Annual Technical Conference and Exhibition, which was held in October in San Antonio, Texas. Conference panels and technical sessions examined best practices and emerging technologies throughout the oil and gas industry, including discussions on the role of data analytics, contemporary research and development initiatives, sustainability, automation, and recent innovations. Here are highlights from this year’s conference. Disruptive Drilling Technology A panel on starting companies selling disruptive drilling technology began with the advice, “If you remember anything today, remember it is not about technology—it is about money.” The advice from Tom Bates, an energy investor from Fort Worth, Texas, began a discussion put on by the Drilling Systems Automation Technical Section (DSATS) about starting successful companies that sell digitally controlled drilling tools. When discussing money, the panelists kept coming back to the critical, sometimes maddening role people play in deciding who gets money and profits in the end. “Most profitable companies do not want things that disrupt” the status quo, said David Blacklaw, Shell global drilling automation lead. For change to happen, it may well require upper management to promote changes that have benefits that are not obvious to those in operations. Even decision makers who see the potential are wary about changes at a time when mass layoffs are a fresh memory. “Automation has a lot of people nervous about their job security,” said Todd Benson, president and CEO of Motive Drilling Technologies. The worries range from decision makers who do not want to stake their job on an unknown startup to workers who see their jobs threatened. Motive Drilling sells a directional drilling advisor, which offers turn-by-turn directions now delivered by directional drillers. While companies using it have continued to employ directional drillers, it changes what they do. If a worker sees something new as a job, “you are the enemy,” Benson said.

The emergency department is an important venue for initial sepsis recognition and care. We sought to determine contemporary estimates of the epidemiology of U.S. emergency department visits for sepsis.Analysis of data from the National Hospital Ambulatory Medical Care Survey.U.S. emergency department visits, 2009-2011.Adult (age, ≥ 18 yr) emergency department sepsis patients. We defined serious infection as an emergency department diagnosis of a serious infection or a triage temperature greater than 38°C or less than 36°C. We defined three emergency department sepsis classifications: 1) original emergency department sepsis-serious infection plus emergency department diagnosis of organ dysfunction, endotracheal intubation, or systolic blood pressure less than or equal to 90 mm Hg or explicit sepsis emergency department diagnoses; 2) quick Sequential Organ Failure Assessment emergency department sepsis-serious infection plus presence of at least two "quick" Sequential Organ Failure Assessment criteria (Glasgow Coma Scale ≤ 14, respiratory rate ≥ 22 breaths/min, or systolic blood pressure ≤ 100 mm Hg); and 3) revised emergency department sepsis-original or quick Sequential Organ Failure Assessment emergency department sepsis.None.We used survey design and weighting variables to produce national estimates of annual adult emergency department visits using updated sepsis classifications. Over 2009-2011, there were 103,257,516 annual adult emergency department visits. The estimated number of emergency department sepsis visits were as follows: 1) original emergency department sepsis 665,319 (0.64%; 95% CI, 0.57-0.73); 2) quick Sequential Organ Failure Assessment emergency department sepsis 318,832 (0.31%; 95% CI, 0.26-0.37); and 3) revised emergency department sepsis 847,868 (0.82%; 95% CI, 0.74-0.91).Sepsis continues to present a major burden to U.S. emergency departments, affecting up to nearly 850,000 emergency department visits annually. Updated sepsis classifications may impact national estimates of emergency department sepsis epidemiology.

Background: Frailty is associated with increased morbidity and mortality in older persons. We sought to characterize the associations between the frailty syndrome and long-term risk of sepsis in a large cohort of community-dwelling adults. Methods: We analyzed data on 30 239 community-dwelling adult participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. We defined frailty as the presence of at least 2 frailty indicators (weakness, exhaustion, and low physical activity). We defined sepsis as hospitalization for a serious infection with ≥2 system inflammatory response syndrome criteria, identified for the period 2003-2012. We determined the associations between frailty and risk of first sepsis and sepsis 30-day case fatality. Results: Among REGARDS participants, frailty was present in 6018 (19.9%). Over the 10-year observation period, there were 1529 first-sepsis hospitalizations. Frailty was associated with increased risk of sepsis (adjusted hazard ratio [HR] 1.44; 95% CI: 1.26 to 1.64). The total number of frailty indicators was associated with increased risk of sepsis ( P trend Conclusions: In the REGARDS cohort, frailty was associated with increased long-term risk of sepsis and sepsis 30-day case fatality.

BACKGROUND: Sepsis may contribute to more than 200 000 annual deaths in the USA. Little is known about the regional patterns of sepsis mortality and the community characteristics that explain this relationship. We aimed to determine the influence of community characteristics upon regional variations in sepsis incidence and case fatality. METHODS: We performed a retrospective analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. Using US sepsis mortality data, we used two strategies for defining geographic regions: (i) Sepsis ‘Belt’ vs Non-Belt and (ii) Sepsis ‘Cluster’ vs Non-Cluster. We determined sepsis incidence and case fatality among REGARDS participants in each region, adjusting for participant characteristics. We examined the mediating effect of community characteristics upon regional variations in sepsis incidence and case fatality. RESULTS: Among 29 680 participants, 16 493 (55.6%) resided in the Sepsis Belt and 2958 (10.0%) resided in a Sepsis Cluster. Sepsis incidence was higher for Sepsis Belt than Non-Belt participants [adjusted hazard ratio (HR) = 1.14; 95% confidence interval (CI) = 1.02–1.24] and higher for Sepsis Cluster than Non-Cluster participants (adjusted HR = 1.18; 95% CI = 1.01–1.39). Sepsis case fatality was similar between Sepsis Belt and Non-Belt participants, as well as between Cluster and Non-Cluster participants. Community poverty mediated the regional differences in sepsis incidence. CONCLUSIONS: Regional variations in sepsis incidence may be partly explained by community poverty. Other community characteristics do not explain regional variations in sepsis incidence or case fatality.

Summary Background The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) present clinical criteria for the classification of patients with sepsis. We investigated incidence and long-term outcomes of patients diagnosed with these classifications, which are currently unknown. Methods We did a retrospective analysis using data from 30 239 participants from the USA who were aged at least 45 years and enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. Patients were enrolled between Jan 25, 2003, and Oct 30, 2007, and we identified hospital admissions from Feb 5, 2003, to Dec 31, 2012, and applied three classifications: infection and systemic inflammatory response syndrome (SIRS) criteria, elevated sepsis-related organ failure assessment (SOFA) score from Sepsis-3, and elevated quick SOFA (qSOFA) score from Sepsis-3. We estimated incidence during the study period, in-hospital mortality, and 1-year mortality. Findings Of 2593 first infection events, 1526 met SIRS criteria, 1080 met SOFA criteria, and 378 met qSOFA criteria. Incidence was 8·2 events (95% CI 7·8–8·7) per 1000 person-years for SIRS, 5·8 events (5·4–6·1) per 1000 person-years for SOFA, and 2·0 events (1·8–2·2) per 1000 person-years for qSOFA. In-hospital mortality was higher for patients with an elevated qSOFA score (67 [23%] of 295 patients died) than for those with an elevated SOFA score (125 [13%] of 960 patients died) or who met SIRS criteria (128 [9%] of 1392 patients died). Mortality at 1 year after discharge was also highest for patients with an elevated qSOFA score (29·4 deaths [95% CI 22·3–38·7] per 100 person-years) compared with those with an elevated SOFA score (22·6 deaths [19·2–26·6] per 100 person-years) or those who met SIRS criteria (14·7 deaths [12·5–17·2] per 100 person-years). Interpretation SIRS, SOFA, and qSOFA classifications identified different incidences and mortality. Our findings support the use of the SOFA and qSOFA classifications to identify patients with infection who are at elevated risk of poor outcomes. These classifications could be used in future epidemiological assessments and studies of patients with infection. Funding National Institute for Nursing Research, National Center for Research Resources, and National Institute of Neurological Disorders and Stroke.

Transcranial Doppler (TCD) is endorsed by national guidelines for use in aneurysmal subarachnoid hemorrhage (aSAH) for surveillance of cerebral vasospasm (CV). However, nationwide data on utilization of TCD for CV detection and monitoring in aSAH are lacking.Analysis of nationwide trends in TCD prevalence was performed using Nationwide Inpatient Sample (NIS) data from 2002 to 2011. Raw counts were converted into weighted counts, which were used to generate national estimates. Teaching hospitals were examined separately for TCD utilization rates. All analyses accounted for the complex sampling design and sample discharge weights of the NIS, following Healthcare Cost and Utilization Project-NIS recommendations. The objective was to estimate the proportion of patients with aSAH receiving TCD monitoring using the NIS.Between 2002 and 2011, a total of 256,089 patients were discharged with a diagnosis of aSAH, of which 3850 underwent TCD monitoring. aSAH accounted for an average of 67.1 discharges per 100,000 annually (95% confidence interval [CI] 61.3-72.8). Of these, 1.5% (95% CI 0.4-2.6) underwent TCD examination. In teaching hospitals, aSAH accounted for an average of 108.5 discharges per 100,000 biennially (95% CI, 96.2-120.8), of which 2% (95% CI 1.0-4.0) underwent TCD examination. TCD utilization increased from1% during the 2002-2005 period to ≥1.5% during the 2006-2011 period (odds ratio 2.3, 95% CI 1.0-5.7), an increase also seen in teaching hospitals.TCD is underused nationally in the care of aSAH. Whereas the prevalence of TCD is low in teaching hospitals, it is nearly nonexistent in nonteaching hospitals.

Background Estimating the strength of causal effects is an important component of epidemiologic research, and causal graphs provide a key tool for optimizing the validity of these effect estimates. Although a large literature exists on the mathematical theory underlying the use of causal graphs, including directed acyclic graphs, to assess and describe causal assumptions, and translate these assumptions into appropriate statistical analysis plans, less literature exists to aid applied researchers in understanding how best to develop and use causal graphs in their research projects. Objective We sought to understand this gap by surveying practicing epidemiologists and medical researchers on their knowledge, level of interest, attitudes, and practices towards the use of causal graphs in applied epidemiology and health research. Methods We conducted an anonymous survey of self-identified epidemiology and health researchers via Twitter and via the Society of Epidemiologic Research membership listserv. The survey was conducted using Qualtrics and asked a series of multiple choice and open-ended questions about causal graphs. Results In total, 439 responses were collected. Overall, a majority of participants reported being comfortable with using causal graphs and reported using them ‘sometimes’, ‘often’, or ‘always’ in their research. Almost three quarters of respondents had received formal training on causal graphs (typically causal directed acyclic graphs). Having received training appeared to improve comprehension of the underlying assumptions of causal graphs. Many of the respondents who did not use causal graphs reported lack of knowledge as a barrier to using DAGs in their research. Of the participants who did not use DAGs, many expressed that trainings, either in-person or online, would be useful resources to help them use causal graphs more often in their research. Conclusion Causal graphs are of interest to epidemiologists and medical researchers, but there are several barriers to their uptake. Additional training and clearer guidance are needed. In addition, methodological developments regarding visualization of effect measure modification and interaction on causal graphs is needed.

It is assumed that medicine treats patients based primarily on their physical illnesses. Sociologic attributes such as religion, nationality, economic class, and gender might inform patient values, but should not negatively affect care. A number of studies, however, suggest that a patient’s sex may influence both the provision of care as well as outcomes. Critical care is not immune to such bias.