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Readmission following Heart failure (HF) hospitalization is common: 25% are readmitted within a month of discharge and ≈50% within 6 months. A small proportion of these patients can have multiple readmissions within this period, adding disproportionately to the health care costs. In this study, we assessed the trends, predictors and costs associated with multiple readmissions using National readmissions database (NRD).We queried NRD for HF hospitalizations from 2010 to 2018 using ICD-9/10-CM codes. Multinomial logistic regression was used to compare readmission cohorts, with the multivariable model adjusting for other factors. All analyses accounted for the NRD sampling design were conducted using SAS v. 9.4 with p0.05 used to indicate statistical significance.Within the study period, an estimated 6,763,201 HF hospitalizations were identified. Of these, 58% had no readmission; 26% had 1 readmission; and 16% had ≥2 readmissions within 90 days of index hospitalization. There was no statistically significant change in readmission rates during the observation period. Multiple readmissions which accounted for 37% of all readmissions contributed to 57% of readmission costs. Younger age was identified as a predictor of multiple readmissions while sex, comorbidities and the type of insurance were not significantly different from those with single readmission.Multiple readmissions in HF are common (16%), have remained unchanged between 2010 and 2018 and impose a significant health care cost burden. Future research should focus on identifying these patients for targeted intervention that may minimize excessive readmissions particularly in those patients who are in the palliation phase of HF.

The full impacts of the COVID-19 pandemic are yet to be determined. While highly effective vaccines are available to prevent and decrease the severity of COVID-19 infection, significant COVID-19 vaccine hesitancy remains. Understanding motivations, discouraging factors, opinions, and information sources regarding COVID-19 is essential to targeting vaccine hesitancy and improving vaccine uptake. A 25 question survey was administered to the patients of a free clinic in the Midwest to assess patient demographic data, opinions about and experience with COVID-19, the COVID-19 vaccines, and information sources. The main outcome of interest was if vaccination status influenced information sources and opinions regarding COVID-19. This study also analyzed motivating and discouraging factors for vaccination. The study had a total of 104 participants with 7 being excluded. There were a total of 97 survey responses included in this study, there were 79 vaccinated patients and 18 unvaccinated patients. This survey study found differences in information sources between vaccinated and unvaccinated groups. Opinions surrounding the COVID-19 vaccine, public health agencies, and perceived severity of COVID-19 also varied between vaccinated and unvaccinated groups. The differential information sources and opinions between vaccinated and unvaccinated groups emphasizes the importance of access to high-quality sources and educating the community to improve public health.

While management guidelines clearly indicate treatment algorithms for ST-segment elevation myocardial infarction, evidence behind treatment of other forms of acute coronary syndrome among diabetic patients has been inconclusive. This study examines diabetic patients with non ST-segment elevation myocardial infarction (NSTEMI) who were subsequently treated conservatively or with an invasive approach.Diabetic patients admitted to our health network with NSTEMI between January 2013-2018 were identified. Data collected included demographics, treatment, survival, recurrence of myocardial infarction (MI), stroke and additional revascularization procedures. Historical data including comorbid factors present at time of NSTEMI and history of revascularization procedures were also collected.A total of 357 patients met exclusion criteria. 172 were treated medically and 185 with PCI. A total of 78 deaths occurred over the five year observation period. 48 patients who were treated medically died while 30 patients treated with PCI died. After initial medical management, nine patients went on to require PCI while 19 patients treated with PCI required additional PCI. Recurrence of MI occurred in 19.8 % in medically managed patients and 18.6 % in patients who underwent PCI. Multivariable analysis was completed with the Kaplan-Meier method to estimate the survival function and Cox proportional-hazard models to investigate association between the variables and survival time.In this single center study, diabetic patients treated with PCI had lower rates of all-cause mortality over the five-year study period compared to medical management. There was no difference in stroke events, recurrent MI, or revascularization between the two groups although patients from the PCI group showed a trend towards higher risk for repeat interventions. Treatment selection bias remains the major limitation of this study and thus, the results of the comparison of therapeutic choices should be viewed as hypothesis generating.

Cardiac troponin (cTn) is a type of protein found in the heart muscles. It is released into the bloodstream when heart muscles become damaged. However, cTn can also be elevated in patients with non-cardiac illnesses, such as critically ill patients and patients with acute gastrointestinal bleeding (AGIB). This study analyzed the relationship between elevated cTn and the outcomes (including prevalence, predictors and mortality) in patients with AGIB. A total of 172 patients with AGIB were evaluated. They were divided into groups based on the presence of elevated cTn. The prevalence of elevated cTn in AGIB patients was 17%. Older age, lower BMI, coronary artery disease and chronic kidney disease were found to be some of the factors that can predict cTn elevation in AGIB patients. AGIB patients with elevated cTn had more cardiology service consultations and procedures and longer lengths of hospital stay. However, there was no effect of elevated cTn on the death rate of AGIB patients.

This review focuses on the use of multilevel models in psychology and other social sciences. We target readers who are catching up on current best practices and sources of controversy in the specification of multilevel models. We first describe common use cases for clustered, longitudinal, and cross-classified designs, as well as their combinations. Using examples from both clustered and longitudinal designs, we then address issues of centering for observed predictor variables: its use in creating interpretable fixed and random effects of predictors, its relationship to endogeneity problems (correlations between predictors and model error terms), and its translation into multivariate multilevel models (using latent-centering within multilevel structural equation models). Finally, we describe novel extensions—mixed-effects location–scale models—designed for predicting differential amounts of variability.

Background Although multiple risk factors for development of pneumonia in patients with trauma sustained in a motor vehicle accident have been studied, the effect of prehospital time on pneumonia incidence post-trauma is unknown. Research Question Is prolonged prehospital time an independent risk factor for pneumonia? Study Design and Methods We retrospectively analyzed prospectively collected clinical data from 806,012 motor vehicle accident trauma incidents from the roughly 750 trauma hospitals contributing data to the National Trauma Data Bank between 2010 and 2016. Results Prehospital time was independently associated with development of pneumonia post-motor vehicle trauma (P Interpretation Increased prehospital time is an independent risk factor for development of pneumonia and increased mortality in patients with trauma caused by a motor vehicle accident. Although prehospital time is often not modifiable, its recognition as a pneumonia risk factor is important, because prolonged prehospital time may need to be considered in subsequent decision-making.

Introduction Major depressive disorder is a serious, recurrent, and disabling psychiatric illness. Despite many proven treatments with multiple medications or therapies, approximately 30% of patients fail to achieve remission and are considered to have treatment-refractory depression (TRD). Recently, there has been a growing interest in the use of intravenous (IV) ketamine for the treatment of TRD. There is limited yet increasing evidence to support the use of ketamine, a glutamate receptor antagonist, in the management of depression; however, the lack of data regarding the safety and tolerability of therapy has limited its clinical use. By analyzing a cohort of veterans with TRD and comorbid psychiatric conditions treated with IV ketamine infusions for a 24-month study period, we aim to provide critical information about ketamine’s clinical effectiveness and safety. Materials and Methods Based on a retrospective chart review, we identified eight veterans with TRD receiving treatment with repeated-dose IV ketamine from 2018 to 2020. The magnitude of clinical response was based on the Beck Depression Inventory self-report scale and the Patient Health Questionnaire-9, both measured at the initial patient consultation and before the beginning of each ketamine infusion treatment. Safety analysis included changes to pre- and post-ketamine infusion on vital signs, effects on alertness and sedation, and potential psychosis-like effects. For all outcomes, we estimated a linear mixed-effects model that allowed heterogeneous residual variances for each veteran. The effect of continuous predictor variables was estimated using restricted cubic splines with knot points specified at the 5th, 35th, 65th, and 95th percentiles. All the analyses were conducted using SAS v.9.4, with P Results During the study period, the median number of ketamine infusions was 15 across a median of 164 days of treatment follow-up with a median time between ketamine infusions of 4 days. For both Beck Depression Inventory and Patient Health Questionnaire-9 scores, there was a statistically significant reduction across infusions (both P Conclusions In this study, repeated-dose IV ketamine infusions over a 24-month study period resulted in a significant reduction in depression scores in a group of veterans with TRD. The rapid onset of significant response, absence of psychosis-like effects or dissociative symptoms despite psychiatric comorbidities, and minimal effects on vital signs support the clinical efficacy and safety of this exciting new treatment option for patients with TRD. Limitations include a 2-year study period, lack of information on long-term effects, and the retrospective nature of the study. Prospective studies of longer duration are needed to assess the long-term efficacy and safety of IV ketamine for TRD.

Background Birthdays provide an opportunity to celebrate; however, they can also be associated with various adverse medical events. This is the first study to examine the association between birthdays and in-hospital trauma team evaluation. Methods This retrospective study analyzed trauma registry patients 19-89 years of age, who were evaluated by in-hospital trauma services from 1/1/2011 to 12/31/2021. Results 14,796 patients were analyzed and an association between trauma evaluation and birthdays was found. The strongest incidence rate ratios (IRRs) were on the day of birth (IRR: 1.78; P < .001) followed by ±3 days of the birthday (IRR: 1.21; P = .003). When incidence was analyzed by age groups, 19-36 years of age had the strongest IRR (2.30; P < .001) on their birthday, followed by the >65 groups (IRR: 1.34; P = .008) within ±3 days. Non-significant associations were seen in the 37-55 (IRR: 1.41; P = .209) and 56-65 groups (IRR: 1.60; P = .172) on their birthday. Patient-level characteristics were only significant for the presence of ethanol at trauma evaluation (risk ratio: 1.83; P = .017). Discussion Birthdays and trauma evaluations were found to have a group-dependent association, with the greatest incidence for the youngest age group being on their birthday, and the oldest age group within ±3 days. The presence of alcohol was found to be the best patient-level predictor of trauma evaluation.

Background Standardization of trauma centers improves quality of care, yet that comes with financial challenges. The decision to designate a trauma center typically focuses on access, quality of care, and the needs of the local community, but less often considers the financial viability of the trauma center. A level-1 trauma center was relocated in 2017 and this presented an opportunity to compare financial data at two separate locations in the same city. Methods A retrospective review was performed on the local trauma registry and billing database in all patients aged ≥19 years on the trauma service before and after the move. Results 3041 patients were included (pre-move: 1151; post-move: 1890). After the move, patients were older (9.5 years), and more were females (14.9%) and white (16.5%). Increases in blunt injuries (7.6%), falls (14.8%), and motor vehicle accidents (1.7%) were observed after the move. After the move, patients were less likely to be discharged home (6.5%) and more likely to go to a skilled nursing facility (3%) or inpatient rehabilitation (5.5%). Post-move more patients had Medicare (12.6%) or commercial (8.5%) insurance and charges per patient decreased by $2,833, while charges collected per patient increased by $2425. Patients were seen from a broader distribution of zip codes post-move. Discussion Relocating a trauma center did improve financial viability for this institution. Future studies should consider the impact on the surrounding community and other trauma centers. Level of evidence Level IV.

Objective Heart Failure (HF) is one of the leading causes of hospitalization in the United States accounting for ≈800,000 hospital discharges and $11 billion in annual costs. Delirium occurs in approximately 30% of elderly hospitalized patients and its incidence is significantly higher among those admitted to the critical care units. Despite this, there has been limited exploration of the clinical and economic impact of delirium in patients hospitalized with acute HF. We hypothesized that delirium in HF is associated with excess mortality and hospital costs. Methods We queried the 2001-2014 Nationwide Inpatient Sample to identify hospitalizations that included a primary discharge diagnosis of HF (ICD-9-CM: 428.xx) and stratified them by presence or absence of delirium (ICD-9-CM: 239.0, 290.41, 293.0, 293.1, 348.31). Differences in in-hospital mortality, length of stay (LOS), and hospital costs were assessed using propensity-score matched cohorts. Results Major predictors of delirium included advanced age, Caucasian race, underlying dementia or psychiatric diagnoses, higher Elixhauser Comorbidity Index, renal failure, cardiogenic shock, and coronary artery bypass surgery. In the propensity-score matched analysis of 76,411 hospitalization with delirium compared to 76,612 without delirium, in-hospital mortality (odds ratio: 1.67, 95% CI: 1.51–1.77), LOS (rate ratio [RR]: 1.47, 95% CI: 1.45–1.51), and hospital costs (RR: 1.44, 95% CI: 1.41–1.48) were all statistically higher in the presence of delirium (all p Conclusion In patients hospitalized with HF, delirium is an independent predictor of increased in-hospital mortality, longer LOS, and excess hospital costs despite adjustment for baseline characteristics.

Physical stressors are common predisposing factors for takotsubo cardiomyopathy (TTC). However, the role of traumatic injuries in TTC has not been well defined. This study describes the characteristics of TTC in the broad spectrum of traumatic injuries using the information available in the National Trauma Data Bank (NTDB).This retrospective study analyzed trauma patients ≥ 18 years old in the NTDB, from 2007 to 2018, with a diagnosis of TTC.A total of 95 TTC diagnoses were found. The median age was 68 years old (interquartile range: 55-80). Patients were predominantly female (67.4%), white (88.4%), and sustained blunt mechanisms of injury (90.5%). Penetrating trauma was most common in males (16%). Most diagnoses were related to extremity trauma (53.7%), followed by head injury (26.3%). The most common severity scores were Glasgow Coma Scale (GCS)13 or8, and Injury Severity Score (ISS)15 or25. Males more commonly presented with GCS8 (68%), ISS25 (33%), high intensive care unit (ICU) admission rate (77.4%), and mechanical ventilation (51.6%). The median duration of the mechanical ventilation was eight days for both sexes. The ICU length of stay (LOS) was six days with a hospital LOS of nine days and a trend toward a longer LOS in males. The in-hospital mortality rate was 11.7% for both sexes.TTC in traumatic injuries is common at both ends of the severity spectrum and has different sex distribution. TTC patients are predominantly females and have more commonly extremity trauma than head injury. Males are more severely injured and under mechanical ventilation.

The evolution of compliance and driving pressure in ARDS and the effects of time spent on noninvasive respiratory support prior to intubation have not been well studied. We conducted this study to assess the effect of the duration of noninvasive respiratory support prior to intubation (ie, noninvasive ventilation [NIV], high-flow nasal cannula [HFNC], or a combination of NIV and HFNC) on static compliance and driving pressure and retrospectively describe its trajectory over time for COVID-19 and non-COVID-19 ARDS while on mechanical ventilation.This is a retrospective analysis of prospectively collected data from one university-affiliated academic medical center, one rural magnet hospital, and 3 suburban community facilities. A total of 589 subjects were included: 55 COVID-19 positive, 137 culture positive, and 397 culture-negative subjects. Static compliance and driving pressure were calculated at each 8-h subject-ventilator assessment.Days of pre-intubation noninvasive respiratory support were associated with worse compliance and driving pressure but did not moderate any trajectory. COVID-19-positive subjects showed non-statistically significant worsening compliance by 0.08 units per subject-ventilator assessment (In contrast to non-COVID-19 ARDS, COVID-19 ARDS was associated with a more ominous trajectory with no improvement in static compliance or driving pressures. Though there was no association between days of pre-intubation noninvasive respiratory support and mortality, its use was associated with worse overall compliance and driving pressure.

Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) optimize percutaneous coronary intervention (PCI) by characterizing lesion morphology, accurately measuring vessel dimensions, and optimizing stent characteristics. We sought to compare the utilization of OCT and IVUS to guide inpatient PCI and their relative association with in-hospital mortality and readmission rates. We queried the National Readmission Database to identify patients undergoing intracoronary imaging-guided PCI from 2010 to 2019 and compared outcomes and readmission rates between patients undergoing OCT-guided PCI and IVUS-guided PCI. Multivariable logistic regression was performed to generate adjusted odds ratios (aOR) of adverse outcomes between the 2 groups. Of 3,71,450 intracoronary imaging-guided PCI admissions, OCT (n = 12,808) was used less frequently than IVUS (n = 358,642). The use of OCT-guided PCI increased from 0.1% in 2010 to 0.6% in 2019 while the rate of IVUS-guided PCI increased from 7.2% in 2010 to 9.4% in 2019 (both ptrend0.001). Patients undergoing OCT compared to IVUS had lower in-hospital mortality (aOR 0.69, P = 0.015) and 30-day readmission rate (aOR 0.91, P = 0.040) with no statistical difference in 90-day readmission rate (aOR 0.93, P = 0.065). Heart failure was the most common cause of 30-day and 90-day readmissions in both cohorts. There was no difference in the rate of acute kidney injury between the 2 modalities. In this in-patient admission database of intracoronary imaging-guided PCI, OCT-guided PCI during index hospitalization appears to be associated with lower in-hospital mortality and 30-day readmission rates compared to IVUS-guided PCI with no difference in terms of the 90-day readmission rates.

The recovery of gastrointestinal functions is an important determinant of course of acute pancreatitis and the timing of hospital discharge. Here, we evaluated association between fluid resuscitation volume and opioid use with clinically significant ileus development in patients with acute pancreatitis. Consecutive adults admitted with acute pancreatitis between January 2014 and December 2019 to our academic and two community hospital were included. The Bedside Index for Severe Acute Pancreatitis (BISAP) and systemic inflammatory response syndrome (SIRS) were used to predict severity of pancreatitis based on their readily availability. Severity of pancreatitis was determined based on the Revised Atlanta classification. Fluid resuscitation volume and opioid use were collected as administered on day 1 and day 2.Clinically significant ileus was determined based on treating physician’s assessment. Forty-nine (11%) of 441 unique patients included in the study developed clinically significant ileus. Demographics of patients with or without ileus were similar between the two groups. On univariate analysis, the presence of SIRS syndrome ( 3 BISAP score (p

Background Although resuscitation with IV fluids is the cornerstone of sepsis management, consensus regarding their association with improvement in clinical outcomes is lacking. Research Question Is there a difference in the incidence of respiratory failure in patients with sepsis who received guideline-recommended initial IV fluid bolus of 30 mL/kg or more conservative resuscitation of less than 30 mL/kg? Study Design and Methods This was a retrospective analysis of prospectively collected clinical data conducted at an academic medical center in Omaha, Nebraska. We abstracted data from 214 patients with sepsis admitted to a single academic medical center between June 2017 and June 2018. Patients were stratified by receipt of guideline-recommended fluid bolus. The primary outcome was respiratory failure defined as an increase in oxygen flow rate or more intense oxygenation and ventilation support; oxygen requirement and volume were measured at admission, 6 h, 12 h, 24 h, and at discharge. Subgroup analyses were conducted in high-risk patients with congestive heart failure (CHF) as well as those with chronic kidney disease (CKD). Results A total of 62 patients (29.0%) received appropriate bolus treatment. The overall rate of respiratory failure was not statistically different between patients who received appropriate bolus or did not (40.3% vs 36.8%; P = .634). Likewise, no differences were observed in time to respiratory failure (P = .645) or risk of respiratory failure (adjusted hazard ratio, 1.1 [95% CI, 0.7-1.7]; P = .774). Results were similar within the high-risk CHF and CKD subgroups. Interpretation In this single-center retrospective study, we found that by broadly defining respiratory failure as an increase in oxygen requirements, a conservative initial IV fluid resuscitation strategy did not correlate with decreased rates of hypoxemic respiratory failure.

Cardiac troponin (cTn) is mainly used to diagnose acute coronary syndrome (ACS). However, cTn can also be elevated in critically ill patients secondary to demand ischemia or myocardial injury. The impact of cardiology consultation on the clinical outcomes of patients admitted to medical intensive care unit (ICU) with elevated cTn is unclear.A retrospective analysis of medical ICU patients with elevated cTn without evidence of ACS between January 2013 through December 2018. Patients were stratified based on documentation of cardiology consultation. The primary outcome was 1-year mortality. Secondary outcomes were in-hospital and 30-day mortality, the length of stay (LOS), further cardiac testing, 30-day readmission rate, new prescription of cardiac medications, and the predictors of a cardiology consultation.Of 846 patients screened, 766 patients were included, of whom 63.2% had cardiology consultation. Cardiology consultation group had longer median LOS (7 vs. 5 days, P = 0.007), additional cardiac testing (90.3% vs. 67.7%, P 0.001), and more new cardiac medications (52.1% vs. 16.3%, P 0.001). No difference was noted in-hospital mortality (adjusted odds ratio [aOR], 0.6, 95% CI, 0.4-1.1, P = .117), 30-day mortality (aOR = 0.8, 95% CI, 0.5-1.4, P = .425), 1- year mortality (aOR, 1.4, 95% CI, 0.9-2.2, P = .193), or cardiac-specific 30-day readmission rate (aOR, 7.0, 95% CI, 0.7-14.9, P = .137). History of coronary artery disease (CAD) was the most independent predictor for a cardiology consult (aOR, 2.2, 95% CI, 1.3-3.8, P .001).Cardiology consultation for elevated cTn in medical ICU patients was associated with increased cardiac testing and LOS, without significant impact on mortality.

Background Diametrically opposed positions exist regarding the deleterious effects of elevated lactate. There are data suggesting that it is a detrimental proxy for tissue hypoperfusion and anaerobic metabolism in sepsis and an alternative viewpoint is that some of the hyperlactatemia produced maybe adaptive. This study was conducted to explore the relationship between serum lactate levels, mean arterial blood pressure (MAP), and sympathetic stimulation in patients with sepsis. Methods Retrospective analysis of prospectively collected clinical data from four community-based hospitals and one academic medical center. 8173 adults were included. Heart rate (HR) was used as a surrogate marker of sympathetic stimulation. HR, MAP, and lactate levels were measured upon presentation. Results MAP and HR interacted to affect lactate levels with the highest levels observed in patients with low MAP and high HR (3.6 mmol/L) and the lowest in patients with high MAP and low HR (2.2 mmol/L). The overall mortality rate was 12.4%. Each 10 beats/min increase in HR increased the odds of death 6.0% (95% CI 2.6% to 9.4%), each 1 mmol/L increase in lactate increased the odds of death 20.8% (95% CI 17.4% to 24.2%), whereas each 10 mmHg increase in MAP reduced the odds of death 12.3% (95% CI 9.2% to 15.4%). However, HR did not moderate or mediate the association between lactate and death. Conclusions In septic patients, lactate production was associated with increased sympathetic activity (HR ≥ 90) and hypotension (MAP

Background There is limited data on the efficacy of direct oral anticoagulants (DOACs) for the treatment of left ventricular thrombus. Currently, vitamin K antagonists (VKAs) remain the preferred oral anticoagulant for left ventricular thrombus. In this retrospective study, we assessed the safety and efficacy of DOACs in comparison to VKAs in patients with a new diagnosis of left ventricular thrombus. Methods We retrospectively identified all patients admitted to the 5 Catholic Health Initiative Omaha hospitals with a diagnosis of left ventricular thrombus between January 2012 and March 2019 and were discharged on oral anticoagulants. Patients were stratified into 2 groups: VKAs or DOACs and followed for up to 1 year. We compared the outcomes of ischemic stroke, bleeding, and echocardiographic resolution of left ventricular thrombus between the 2 groups. Results A total of 99 patients were included in this study (mean age: 61 years, 29% females). Of these, 80 (81%) were discharged on VKAs and 19 (19%) on DOACs. Stroke within 1 year of diagnosis occurred in 2 patients in the VKA group and none in the DOAC group (P = 0.49). Bleeding events were observed in 5 patients (4 in the VKA group and 1 in the DOAC group; P = 0.96). Ninety patients had follow-up echocardiogram; resolution of left ventricular thrombus was similar between the 2 groups (VKAs vs DOACs: 81% vs 80%; P = 0.9). Conclusion In patients with left ventricular thrombus, DOACs and VKAs had similar rates of stroke and bleeding. These findings need confirmation in randomized clinical trials.

To assess readmission rates in nonagenarians (age ≥ 90 years) with ST-elevation myocardial infarction (STEMI) following primary percutaneous coronary intervention (pPCI) versus no pPCI.There are limited data exploring readmissions following STEMI in nonagenarians undergoing pPCI versus no pPCI.We retrospectively analyzed the Nationwide Readmissions Database to identify nonagenarians hospitalized with STEMI. We divided the cohort into two groups based on pPCI status. We compared mortality during index hospitalization and during 30-day readmission, readmission rates, and causes of readmissions.We identified 58,231 nonagenarian STEMI hospitalizations between 2010 and 2018, of which 18,809 (32.3%) included pPCI, and 39,422 (67.7%) had no pPCI. Unadjusted unplanned 30-day readmission was higher in pPCI cohort (21.0% vs. 15.4%, p 0.001). However, mortality during index hospitalization and during 30-day readmission were significantly lower in pPCI cohort (15.8% vs. 32.2%, p 0.001; 7.4% vs. 14.2%, p 0.001, respectively). After adjusting for baseline characteristics, hospitalizations that included pPCI had 25% greater odds of unplanned 30-day readmission (adjusted odds ratio [aOR]: 1.25, 95% confidence interval [CI]: 1.12-1.39, p 0.001) and 49% lower odds of in-hospital mortality during index hospitalization (aOR: 0.51, 95% CI: 0.46-0.56, p 0.001). Heart failure was the most common cause of readmission in both cohorts followed by myocardial infarction.In nonagenarians with STEMI, pPCI is associated with slightly higher 30-day readmission but significantly lower mortality during index hospitalization and during 30-day readmission than no pPCI. Given the overwhelming mortality benefit with pPCI, further research is necessary to optimize the utilization of pPCI while reducing readmissions following STEMI in nonagenarians.

PURPOSE: To assess the current state of training among U.S. Obstetrics and Gynecology (OB/Gyn) residents in the field of transgender medicine. METHODS: An anonymous survey was sent to current OB/Gyn residents in the United States, which contained a series of questions regarding their training experiences caring for transgender patients. RESULTS: Roughly half of respondents (49.4%) reported having formal didactics in transgender medicine or personal experience caring for a transgender patient (46.8%). Only 14.5% of respondents had any surgical training, and 59% responded that they had at least some comfort level caring for transgender patients. Of the areas of care assessed, residents felt most comfortable providing appropriate cancer screening to transgender patients and least comfortable with gender-affirming hormone therapy management. Just 50.3% of respondents felt that they worked with at least one faculty member with expertise in transgender medicine, and more than half (51.1%) responded that they felt there were barriers to training in their program, with 14% reporting a perceived atmosphere of bias or discrimination toward this patient population. The majority of residents (82.6%) expressed interest in additional training in this field, with direct patient exposure and didactic lectures identified as being the most desired learning modalities. CONCLUSION: Approximately half of resident respondents reported didactic exposure to transgender medicine in their current programs, with far fewer having surgical training. At least half of respondents felt that there were barriers to their training in transgender medicine, and a majority of respondents were interested in further training in this field.

OBJECTIVES Multiple studies have demonstrated an obesity paradox such that obese ICU patients have lower mortality and better outcomes. We conducted this study to determine if the mortality benefit conferred by obesity is affected by baseline serum lactate and mean arterial pressure. DESIGN Retrospective analysis of prospectively collected clinical data. SETTING Five community-based and one academic medical center in the Omaha, NE. PATIENTS 7,967 adults hospitalized with sepsis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were categorized by body mass index as underweight, normal weight, overweight, or obese. Multivariable logistic regression models were used to estimate the odds of in-hospital death by body mass index category; two-way interactions between body mass index and each covariate were also evaluated. Subgroup and sensitivity analyses were conducted using an ICU cohort and Acute Physiology and Chronic Health Evaluation III scores, respectively. The overall unadjusted mortality rate was 12.1% and was consistently lower in higher body mass index categories (all comparisons, p < 0.007). The adjusted mortality benefit observed in patients with higher body mass index was smaller in patients with higher lactate levels with no mortality benefit in higher body mass index categories observed at lactate greater than 5 mmol/L. By contrast, the association between lower MAP and higher mortality was constant across body mass index categories. Similar results were observed in the ICU cohort. Finally, the obesity paradox was not observed after including Acute Physiology and Chronic Health Evaluation III scores as a covariate. CONCLUSIONS Our retrospective analysis suggests that although patient size (i.e., body mass index) is a predictor of in-hospital death among all-comers with sepsis-providing further evidence to the obesity paradox-it adds that illness severity is critically important whether quantified as higher lactate or by Acute Physiology and Chronic Health Evaluation III score. Our results highlight that the obesity paradox is more than a simple association between body mass index and mortality and reinforces the importance of illness severity.

Hill’s classification provides a reproducible endoscopic grading system for esophagogastric junction morphology and competence, specifically whether the gastroesophageal flap valve (GEFV) is normal (grade I/II) or abnormal (grades III/IV). However, it is not routinely used in clinical practice. We report a systematic review and meta-analysis to determine association between abnormal GEFV and gastroesophageal reflux disorder (GERD). A comprehensive literature search of MEDLINE and Scopus databases was conducted to identify studies that reported the association between abnormal GEFV and GERD. The search and quality assessment were performed independently by two authors. Fixed- and random-effects meta-analyses were conducted using symptomatic GERD and erosive esophagitis as outcomes. A total of 11 studies met inclusion criteria that included a total of 5054 patients. In the general population, patients with abnormal GEFV had greater risk of symptomatic GERD compared to patients with a normal GEFV (risk ratio [RR] 1.88, 95% CI 1.57–2.24). Further, in patients with symptomatic GERD, patients with abnormal GEFV had greater risk of erosive esophagitis compared to patients with normal GEFV (RR 2.17, 95% CI 1.40–3.36). Finally, the specificity of abnormal GEFV for symptomatic GERD was 73.3% (95% CI 69.3–77.0%) and 75.7% (95% CI 65.9–83.4%) for erosive esophagitis in symptomatic GERD. Our systematic review and meta-analysis showed consistent association between abnormal GEFV indicated by Hill’s classification III/IV and symptomatic GERD and erosive esophagitis. Our recommendation is to include Hill’s classification in routine endoscopy reports and workup for GERD.

While aortic valve replacement (AVR) is indicated for symptomatic severe aortic stenosis (AS), the appropriate management of asymptomatic severe AS remains unclear. We conducted an updated meta-analysis to compare the outcomes of surgical AVR (SAVR) versus conservative treatment in patients with asymptomatic severe AS.We searched PubMed, EMBASE, Cochrane, clinicaltrials.gov, and Google Scholar for studies comparing outcomes of SAVR versus conservative treatment in asymptomatic severe AS. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for each individual study. Outcomes included all-cause mortality, cardiovascular and non-cardiovascular mortality, 30-day operative mortality, sudden cardiac death (SCD), heart failure hospitalization (HFH), myocardial infarction (MI), and stroke.A total of 8 studies with 2685 patients were included. The mean age was above 60 years, and the median follow-up duration was 4 years. Compared to conservative treatment, SAVR was associated with significantly lower all-cause mortality (RR 0.39; 95% CI 0.23-0.64) and HFH rates (RR 0.18; 95% CI 0.05-0.71). There were no significant differences in cardiovascular mortality (RR 0.24; 95% CI 0.03-1.67), non-cardiovascular mortality (RR 0.49; 95% CI 0.23-1.03), 30-day operative mortality (RR 0.48; 95% CI 0.10-2.32), SCD (RR 0.37; 95% CI 0.05-2.89), MI (RR 0.48; 95% CI 0.04-5.52), and stroke rates (RR 1.20; 95% CI 0.35-4.11) between the two strategies.In patients with asymptomatic severe AS, SAVR is associated with significantly lower all-cause mortality and HFH compared to conservative treatment. While SAVR is a promising option for asymptomatic severe AS, most studies were observational and nonrandomized; randomized trials are needed to establish a clear benefit.

Constructs that reflect differences in variability are of interest to many researchers studying workplace phenomena. The aggregation methods typically used to investigate “variability-based” constructs suffer from several limitations, including the inability to include Level 1 predictors and a failure to account for uncertainty in the variability estimates. We demonstrate how mixed-effects location-scale (MELS) and heterogeneous variance models, which are direct extensions of traditional mixed-effects (or multilevel) models, can be used to test mean (location)- and variability (scale)-related hypotheses simultaneously. The aims of this article are to demonstrate (a) how the MELS and heterogeneous variance models can be estimated with both nested cross-sectional and longitudinal data to answer novel research questions about constructs of interest to organizational researchers, (b) how a Bayesian approach allows for the inclusion of random intercepts and slopes when predicting both variability and mean levels, and finally (c) how researchers can use a multilevel approach to predict between-group heterogeneous variances. In doing so, this article highlights the added value of viewing variability as more than a statistical nuisance in organizational research.

Background:The evolution of compliance and driving pressure in acute respiratory distress syndrome (ARDS) and the effects of time spent on noninvasive respiratory support prior to intubation has not been well studied. We conducted this study to assess the effect of the duration of noninvasive respiratory support prior to intubation (i.e., Noninvasive ventilation (NIV), High flow nasal cannula (HFNC), or a combination of NIV and HFNC) on static compliance and driving pressure and retrospectively describe its trajectory over time for COVID-19 and non-COVID-19 ARDS while on mechanical ventilation. Methods: Retrospective analysis of prospectively collected data from one university-affiliated academic medical center, one a rural magnet hospital, and three suburban community facilities. A total of 589 patients were included: 55 COVID-19 positive, 137 culture positive, and 397 culture negative patients. Static compliance and driving pressure were calculated at each 8-hour ventilator check. Results:Days of pre-intubation noninvasive respiratory support was associated with worse compliance and driving pressure but did not moderate any trajectory. COVID-19 positive patients showed non-statistically significant worsening compliance by 0.08-units per ventilator check (p = .241), whereas COVID-19 negative patients who were either culture positive or negative patients showed statistically significant improvement (0.12 and 0.18, respectively; both p < .05); a statistically similar but inverse pattern was observed for driving pressure. ConclusionIn contrast to non-COVID-19 ARDS, COVID-19 ARDS was associated with a more ominous trajectory with no improvement in static lung compliance or driving pressures. Though there was no association between days of pre-intubation noninvasive respiratory support and mortality, its use was associated with worse overall compliance and driving pressure.

BACKGROUND Patients undergoing transcatheter edge-to-edge mitral valve repair (TEER) carry a high risk of rehospitalization due to disease, procedure, patient, hospital, and system related factors. AIMS We aimed to explore the impact of gender on in-hospital mortality and 90-day readmissions in patients undergoing TEER. METHODS We utilized the National Readmission Database from 2012 to 2018 to identify individuals who underwent TEER for mitral regurgitation. Gender-based differences in in-hospital mortality and 90-day readmissions were explored using multivariable logistic regression models. RESULTS Between 2012 and 2018, an estimated 21,415 TEER procedural hospitalizations were identified, of which 9893 (46.2%) were in women and 11,522 (53.8%) were in men. Compared with men, women were older, from a lower socioeconomic status but had a lower co-morbidity burden. In-hospital mortality rate during the index hospitalization was similar in women and men (2.1% vs. 2.1%, p = 0.908). Ninety-day all-cause and heart failure readmission rates were significantly higher in women compared to men (30.2% vs. 25.4%; p

Prions are comprised solely of PrPSc, the misfolded self-propagating conformation of the cellular protein, PrPC. Synthetic prions are generated in vitro from minimal components and cause bona fide prion disease in animals. It is unknown, however, if synthetic prions can cross the species barrier following interspecies transmission. To investigate this, we inoculated Syrian hamsters with murine synthetic prions. We found that all the animals inoculated with murine synthetic prions developed prion disease characterized by a striking uniformity of clinical onset and signs of disease. Serial intraspecies transmission resulted in a rapid adaptation to hamsters. During the adaptation process, PrPSc electrophoretic migration, glycoform ratios, conformational stability and biological activity as measured by protein misfolding cyclic amplification remained constant. Interestingly, the strain that emerged shares a strikingly similar transmission history, incubation period, clinical course of disease, pathology and biochemical and biological features of PrPSc with 139H, a hamster adapted form of the murine strain 139A. Combined, these data suggest that murine synthetic prions are comprised of bona fide PrPSc with 139A-like strain properties that efficiently crosses the species barrier and rapidly adapts to hamsters resulting in the emergence of a single strain. The efficiency and specificity of interspecies transmission of murine synthetic prions to hamsters, with relevance to brain derived prions, could be a useful model for identification of structure function relationships between PrPSc and PrPC from different species., Author summary Prions have zoonotic potential as illustrated by the interspecies transmission of bovine spongiform encephalopathy to humans resulting in the emergence of a novel human prion disease. It is unknown if other prion diseases of animals, such as chronic wasting disease, can be transmitted to other species. Models to predict prion zoonotic potential do not exist, in part, due to the lack of understanding of how the structure of PrPSc from one species can convert PrPC from another species. Towards this end, we determined that murine synthetic prions, made from minimal components, can efficiently establish infection in hamsters whose transmission history, clinical features, pathology and biochemical properties of PrPSc are consistent with the reisolation of a known prion strain. We conclude that murine synthetic prions can recapitulate interspecies transmission and adaptation allowing for a more detailed mechanistic analysis in a simplified, trackable system.

While human papilloma virus (HPV) vaccinations and Pap smear screenings are known to improve the survival rates and incidence of cervical cancer, refugee populations have traditionally been disadvantaged within this arena. Due to past and recent political issues in Myanmar, Burmese refugee women in Nebraska may be at particular risk due to their increasing numbers. This study examined 65 female Burmese refugees who were candidates for HPV vaccinations and 106 female Burmese refugees who could have received Pap smear screenings between 2010 and 2020. Of the 65 patients aged 11–26, 49.2% initiated the HPV vaccine series and 30.8% completed the series. In patients aged 13–17, 86.4% initiated the vaccine series and 54.6% completed the series. Of the 106 patients over 18 years of age, 32.1% had a Pap smear within the last 3 years. The need to improve HPV vaccine and Pap smear rates in refugee populations is clear. While focusing on the designated refugee exam may have improved HPV vaccine rates, it is important to examine gaps in knowledge with regards to attitudes surrounding HPV vaccines and Pap smears within the Burmese refugee population.

Background: Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a frequently performed procedure. Suction is utilized during this procedure and may occasionally result in the collection of aspirated material, the diagnostic utility of which is uncertain. This study aims to determine the contents of the suction syringe aspirate and its diagnostic value. Methods: The suction syringe aspirate was pooled in a container and sent for analysis. We retrospectively reviewed the cytological outcomes of these specimens in comparison to the diagnosis determined by EBUS-TBNA between 2015–2018. The primary outcome was the percent agreement between the diagnostic material found in the suction syringe aspirate, and the final diagnosis established by EBUS-TBNA. Results: Forty-four patients were included. Percent agreement was calculated as the percent in which the suction syringe aspirate diagnosis agreed with the EBUS-TBNA diagnosis. The percent agreement of any diagnosis was 90.9% (95% CI: 78.7–97.2%). Two of the 44 diagnoses (4.5%) were established based solely on the suction syringe aspirate, both cases of granulomatous inflammation. Conclusions: Our results suggest that material collected in the suction syringe has a very high percent agreement with the final diagnosis established by EBUS-TBNA. Furthermore, the suction syringe aspirate may represent the sole diagnostic material in nearly 5% of cases. Given the additional diagnostic material in the suction syringe aspirate, it is reasonable to pool the aspirate with the primary specimen in an effort to enrich the overall diagnostic specimen. This practice may improve the likelihood that the specimen will be sufficient for additional molecular analysis, although further study is necessary. Care must be taken when more than one needle is involved to ensure that a new suction syringe is also used to avoid inadvertent upstaging by specimen contamination.

The aim of this study was to determine the recent trends of the rates of hospitalization, mortality of hospitalized patients, and associated health care utilization in patients with acute pancreatitis (AP).We identified adult patients with primary discharge diagnosis of AP from the National Inpatient Sample database. Patients with chronic pancreatitis and/or pancreatic cancer were excluded. Primary outcomes included age-adjusted incidence of AP and in-hospital mortality based on US standard population derived from the 2000 census data. Secondary outcomes were length of stay, inflation-adjusted hospital costs in 2014 US dollars, and procedural rates. Subgroup analysis included disease etiologies, age, race, sex, hospital region, hospital size, and institution type.From 2001 to 2014, the rate of primary discharge diagnosis for AP increased from 65.38 to 81.88 per 100,000 US adults per year. In-hospital case fatality decreased from 1.68% to 0.69%. Mortality rate is higher in patients with AP who are older than 65 years (3.4%). Length of stay decreased, with a median of 3.8 days; cost per hospitalization decreased since 2007 from $7602 to $6766 in 2014.The rate of hospitalization related to AP in the United States continues to increase. Mortality, length of stay, and cost per hospitalization decrease. The increase in volume of hospitalization might contribute to an overall increase in health care resource utilization.