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Reiche WS, Walters RW, Schutte BF, Mukherjee S, Buaisha HM. Mild Thrombocytopenia, a Predictor of Outcomes After Laparoscopic Cholecystectomy: Assessment of Surgical Risk in Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease. J Clin Gastroenterol 2024; 58:507-515. [PMID: 37702741 PMCID: PMC10994184 DOI: 10.1097/mcg.0000000000001926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/20/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND A common cause of mild thrombocytopenia is chronic liver disease, the most common etiology being metabolic dysfunction-associated steatotic liver disease (MASLD). Mild thrombocytopenia is a well-defined, independent marker of hepatic fibrosis in patients with chronic liver disease. Currently, there is a paucity of information available to characterize perioperative risk in patients with MASLD; therefore, the characterization of perioperative morbidity is paramount. We used a platelet threshold of 150×10 9 as a surrogate for fibrosis in patients undergoing laparoscopic cholecystectomy to study its effect on perioperative complications and mortality. PATIENTS AND METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program database for laparoscopic cholecystectomies occurring from 2005 through 2018. Demographic differences between patients with and without thrombocytopenia were evaluated using the t test or the χ 2 test, whereas adjusted and unadjusted differences in outcome risk were evaluated using log-binomial regression models. RESULTS We identified 437,630 laparoscopic cholecystectomies of which 6.9% included patients with thrombocytopenia. Patients with thrombocytopenia were more often males, older, and with chronic disease. Patients with thrombocytopenia and higher Aspartate Aminotransferase to Platelet Ratio Index scores had 30-day mortality rates risk ratio of 5.3 (95% CI: 4.8-5.9), with higher complication rates risk ratio of 2.4 (95% CI: 2.3-2.5). The most frequent complications included the need for transfusion, renal, respiratory, and cardiac. CONCLUSIONS Perioperatively, patients with mild thrombocytopenia undergoing laparoscopic cholecystectomy had higher mortality rates and complications compared with patients with normal platelet counts. Thrombocytopenia may be a promising, cost-effective tool to identify patients with MASLD and estimate perioperative risk, especially if used in high-risk populations.
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Affiliation(s)
- William S. Reiche
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Ryan W. Walters
- Department of Clinical Research and Public Health, Creighton University School of Medicine
| | - Bryce F. Schutte
- Department of Medicine, CHI Creighton University Medical Center, Omaha, NE
| | - Sandeep Mukherjee
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Haitam M. Buaisha
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
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Wilson NC, Dilsaver DB, Walters RW, Nandipati KC. Bariatric Surgery Outcomes in Patients with Inflammatory Bowel Disease in the United States: An Analysis of the Nationwide Readmissions Database. Obes Surg 2024; 34:1279-1285. [PMID: 38413497 PMCID: PMC11026179 DOI: 10.1007/s11695-024-07111-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE Bariatric surgery has been reported to produce durable weight loss in the management of obesity; sleeve gastrectomy (SG) is the most common bariatric procedure. Obesity is a common comorbidity of inflammatory bowel disease (IBD), and the impact of IBD on short-term SG outcomes has not been widely reported. This study assessed whether IBD was associated with adverse post-SG outcomes. MATERIALS AND METHODS Hospitalizations of patients undergoing SG in the United States were identified using the 2010-2020 Nationwide Readmissions Database (NRD) and stratified by IBD diagnosis. The SG cohort was propensity-matched based on age, biological sex, body mass index (BMI), comorbid diabetes, hypertension, depression, chronic obstructive pulmonary disease, and discharge in quarter four. Primary aims were to compare in-hospital mortality, post-operative complications, and all-cause 90-day readmission between patients with and without IBD. Secondary outcomes were length of stay (LOS) and total hospital cost. RESULTS A total of 2030 hospitalizations were matched. The odds of complication were 48% higher for hospitalizations of patients with IBD (11.1% vs. 7.8%; aOR 1.48, aOR 95% CI 1.10-2.00, p = .009). The most common complication was nausea (4.9% vs. 3.7%, p = .187). No statistically significant difference was observed for all-cause 90-day readmissions, LOS, or hospital cost. CONCLUSION Hospitalizations of patients with IBD who underwent SG experienced significantly higher post-operative complication rates. However, the similar lengths of stay and readmission rates compared to propensity-matched SG hospitalizations without IBD suggest many complications were minor. SG remains a safe weight loss procedure for patients suffering from IBD and obesity.
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Affiliation(s)
- Noah C Wilson
- School of Medicine, Creighton University, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Danielle B Dilsaver
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, 7710 Mercy Road, Education Building, Suite 502, Omaha, NE, 68124, USA
| | - Ryan W Walters
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, 7710 Mercy Road, Education Building, Suite 502, Omaha, NE, 68124, USA
| | - Kalyana C Nandipati
- Department of Surgery, School of Medicine, Creighton University, 7710 Mercy Road, Education Building, Suite 501, Omaha, NE, 68124, USA.
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Petersen J, Abusnina W, Beesabathina S, Desu SS, Walters RW, Alla VM. Racial Disparities in Outcomes of Delivery and Cardiac Complications Among Pregnant Women with Congenital Heart Disease. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-01950-0. [PMID: 38416292 DOI: 10.1007/s40615-024-01950-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 02/29/2024]
Abstract
Advances in cardiology have led to improved survival among patients with congenital heart disease (CHD). Racial disparities in cardiovascular and maternal outcomes are well known and are likely to be more profound among pregnant women with CHD. Using the 2001 to 2018 National Inpatient Sample, we identified all hospitalizations for delivery among women ≥ 18 years of age with CHD. Unadjusted and adjusted between-race differences in adverse maternal cardiovascular, obstetric, and fetal events were assessed using logistic regression models. During the study period, we identified 52,711 hospitalizations for delivery among women with concomitant CHD. Of these, 66%, 11%, and 16% were White, Black, and Hispanic, respectively. Obstetric complications and fetal adverse events were higher among Blacks compared to Whites and Hispanics (44% vs. 33% vs. 37%, p < .001; 36% vs. 28% vs. 30%, p < .001), respectively. No between-race differences were observed in overall cardiovascular adverse events (27% vs. 24% vs. 23%, p < .21). However, heart failure was significantly higher among Black women (3.6% vs. 1.7% vs. 2.2%, p = 0.001). While a lower income quartile was associated with higher rates of adverse outcomes, adjustment for income did not attenuate the adverse impact of race. Black females with CHD diagnoses were more likely to experience adverse obstetric, fetal events, and heart failure compared to White and Hispanic women irrespective of their income status. Further research is needed to identify causes and devise interventions to mitigate racial disparities in the care of pregnant women with CHD.
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Affiliation(s)
- John Petersen
- Creighton University School of Medicine, Omaha, NE, USA
| | - Waiel Abusnina
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | | | | | - Ryan W Walters
- Department of Clinical Research and Public Health, Creighton University School of Medicine, Omaha, NE, USA
| | - Venkata Mahesh Alla
- Division of Cardiology, Creighton University School of Medicine, 7710 Mercy Rd., Suite #401, Omaha, NE, 68123, USA.
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Kim KM, Walters RW, Kim MH. Health-Related Social Needs, Social Determinants, and Readmissions in Adults With Congenital Heart Disease. J Am Heart Assoc 2024; 13:e032583. [PMID: 38258655 PMCID: PMC11056125 DOI: 10.1161/jaha.123.032583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024]
Affiliation(s)
- Kathryn M. Kim
- Department of MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
| | - Ryan W. Walters
- Department of MedicineCreighton University School of MedicineOmahaNEUSA
| | - Michael H. Kim
- Department of MedicineCreighton University School of MedicineOmahaNEUSA
- CHI HealthOmahaNEUSA
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Abusnina W, Elhouderi E, Walters RW, Al-Abdouh A, Mostafa MR, Liu JL, Mazozy R, Mhanna M, Ben-Dor I, Dufani J, Kabach A, Michos ED, Aboeata A, Mamas MA. Sex Differences in the Clinical Outcomes of Patients With Takotsubo Stress Cardiomyopathy: A Meta-Analysis of Observational Studies. Am J Cardiol 2024; 211:316-325. [PMID: 37923154 DOI: 10.1016/j.amjcard.2023.10.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 10/13/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
The incidence of takotsubo stress cardiomyopathy (TSCM) in males is low compared with females. Gender-based differences in clinical outcomes of TSCM are not well characterized. The aim of this meta-analysis was to analyze whether gender-based differences are observed in TSCM clinical outcomes. A comprehensive literature search of PubMed, Embase, Cochrane Library database, and Web of Science was performed from inception to June 20, 2022, for studies comparing the clinical outcomes between male and female patients with TSCM. The primary outcome of interest was in-hospital all-cause mortality and cardiogenic shock. The secondary outcomes were cardiovascular mortality, receipt of mechanical ventilation, intra-aortic balloon pump, occurrence of ventricular arrhythmia, and left ventricular thrombus. A random-effects model was used to calculate the risk ratios (RR) and confidence intervals (CI). Heterogenicity was assessed using the Higgins I2 index. Twelve observational studies involving 51,213 patients (4,869 males and 46,344 females) were included in the meta-analysis. Male gender was associated with statistically significant higher in-hospital all-cause mortality compared with females in patients with TSCM (RR 2.17, 95% CI 1.77 to 2.67, p <0.001). The rate of cardiogenic shock was significantly higher in males with TSCM compared with females (RR 1.66, 95% CI 1.29 to 2.12, p <0.001). Our meta-analysis showed a difference in the clinical outcomes of TSCM between men and women. Male gender was associated with a two-fold greater in-hospital all-cause mortality risk compared with female gender. The higher mortality risk associated with male gender deserves further study, particularly whether it represents later recognition of the condition and disparities in treatments.
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Affiliation(s)
- Waiel Abusnina
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA; Section of Interventional Cardiology, Medstar Washington Hospital Center, Washington DC.
| | - Eiman Elhouderi
- Department of Medicine, Beaumont Hospital, Dearborn, MI, USA
| | - Ryan W Walters
- Department of Clinical Research and Public Health, Creighton University School of Medicine, Omaha, NE, USA
| | - Ahmad Al-Abdouh
- Division of Hospital Medicine, University of Kentucky, Lexington, KY, USA
| | - Mostafa R Mostafa
- Department of Medicine, Rochester Regional Health/Unity Hospital, Rochester, New York, USA
| | - John L Liu
- Creighton University School of Medicine, Omaha, NE, USA
| | - Ruqayah Mazozy
- Department of Cardiology, Zliten Medical Center, Zliten, Libya
| | - Mohammed Mhanna
- Division of Cardiology, Department of Medicine, University of Iowa, IA, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, Medstar Washington Hospital Center, Washington DC
| | - Jalal Dufani
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA
| | - Amjad Kabach
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahemd Aboeata
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA
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Fuji KT, White ND, Packard KA, Kalkowski JC, Walters RW. Effect of a Financial Education and Coaching Program for Low-Income, Single Mother Households on Child Health Outcomes. Healthcare (Basel) 2024; 12:127. [PMID: 38255016 PMCID: PMC10815544 DOI: 10.3390/healthcare12020127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/23/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
The financial difficulties of parents have a negative impact on the health of their children. This problem is more pronounced in single mother families. There is limited research on low-income, single mothers and how interventions to help them address financial difficulties may also benefit their children. The purpose of this study was to evaluate the effect of a year-long financial education and coaching program on school absenteeism and health care utilization of children in employed, low-income, single mother households. This was a post hoc analysis of the Finances First study, a randomized controlled trial conducted in 2017-2020 examining the impact of a financial coaching and education program on economic stability and health outcomes in 345 low-income, single mothers. Either generalized estimating equations (GEEs) or generalized linear mixed models (GLMMs) were used to account for relationships between participants. For the continuous outcomes of child absenteeism, physician visits, emergency room visits, and hospitalization days, a linear mixed-effects model was used. The Finances First study demonstrated improvements in various financial strain measures. Compared to the control group, children of intervention group participants experienced 1 fewer day of school absence (p = 0.049) and 1 fewer physician visit (p = 0.032) per year, but no impact was seen on emergency room visits (p = 0.55) or hospitalizations (p = 0.92). Addressing social determinants of health in parents is necessary for improving child health outcomes.
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Affiliation(s)
- Kevin T. Fuji
- Department of Pharmacy Sciences, School of Pharmacy and Health Professions, Creighton University, Omaha, NE 68178, USA
| | - Nicole D. White
- Department of Pharmacy Practice, School of Pharmacy and Health Professions, Creighton University, Omaha, NE 68178, USA
| | - Kathleen A. Packard
- Department of Pharmacy Practice, School of Pharmacy and Health Professions, Creighton University, Omaha, NE 68178, USA
| | - Julie C. Kalkowski
- Financial Hope Collaborative, Heider College of Business, Creighton University, Omaha, NE 68178, USA
| | - Ryan W. Walters
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, Omaha, NE 68178, USA
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7
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Guck TP, Walters RW, Abdul-Greene C, Doll J, Greene MA, McGaha AL. Sustainable and replicable clinical and financial outcomes in an interprofessional education and collaborative practice nexus. J Interprof Care 2024; 38:70-77. [PMID: 34139943 DOI: 10.1080/13561820.2021.1932776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
Our Interprofessional Education and Collaborative Practice (IPECP) Nexus previously reported significant reductions in Emergency Department (ED) visits, hospitalizations, hemoglobin A1c levels, and patient charges. This study examines sustainability of these results over two additional years and replication in two subsequent independent patient cohorts. Participants in the sustainability cohort (N = 276) met ≥1 of the following criteria: (a) ≥3 ED visits in first or second half of the year, (b) hemoglobin A1c level ≥ 9, or (c) Length of Stay, Acuity, Comorbidities, and ER (Emergency Room) Visits (LACE) score ≥ 10. Participants in two replicability cohorts (N = 255) and (N = 160) met the same criteria, but the LACE criterion was changed to ≥3 hospitalizations in baseline years. The Nexus, housed in a family medicine (FM) residency clinic, included professionals and students from multiple disciplines. IPECP skills and interventions included communication, team building, and conflict engagement skills training, daily huddles and pre-visit planning, immediate consultations, small teamlet IPECP interactions, and weekly IPECP case conferences for complex patients. Original health improvements and charge reductions were sustained for two additional years for ED visits, hospitalizations, A1c, and patient charges, and replicated in two additional patient cohorts. The IPECP Nexus interventions were associated with Quadruple Aim outcomes while training the next generation of health care professionals.
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Affiliation(s)
- Thomas P Guck
- Creighton University School of Medicine, Creighton University, Omaha, NE, USA
| | - Ryan W Walters
- Creighton University School of Medicine, Creighton University, Omaha, NE, USA
| | | | - Joy Doll
- Creighton University School of Medicine, Creighton University, Omaha, NE, USA
| | - Michael A Greene
- Creighton University School of Medicine, Creighton University, Omaha, NE, USA
- CHI Health Creighton University Medical Center, University Campus
| | - Amy L McGaha
- Creighton University School of Medicine, Creighton University, Omaha, NE, USA
- CHI Health Creighton University Medical Center, University Campus
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Holland EM, Dilsaver DB, Walters RW, Kim MH. Relationship of health-related social needs, social determinants of health, and catheter ablation utilization in atrial fibrillation : Social needs and application of atrial fibrillation ablation. J Interv Card Electrophysiol 2024; 67:39-41. [PMID: 37715076 PMCID: PMC10769929 DOI: 10.1007/s10840-023-01646-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/11/2023] [Indexed: 09/17/2023]
Affiliation(s)
- Eva M Holland
- Dept of Medicine Creighton University School of Medicine, 7710 Mercy Rd, Suite 301, Omaha, NE, 68124, USA
| | - Danielle B Dilsaver
- Dept of Medicine Creighton University School of Medicine, 7710 Mercy Rd, Suite 301, Omaha, NE, 68124, USA
| | - Ryan W Walters
- Dept of Medicine Creighton University School of Medicine, 7710 Mercy Rd, Suite 301, Omaha, NE, 68124, USA
| | - Michael H Kim
- Dept of Medicine Creighton University School of Medicine, 7710 Mercy Rd, Suite 301, Omaha, NE, 68124, USA.
- CHI Health, Omaha, NE, USA.
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9
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Jizba TA, Ahmad F, Walters RW, Foral PA, Destache CJ, Velagapudi M. A comparison of clinical outcomes associated with dosing metronidazole every 8 hours versus every 12 hours: a systematic review and metaanalysis. Proc AMIA Symp 2023; 37:127-134. [PMID: 38174024 PMCID: PMC10761045 DOI: 10.1080/08998280.2023.2282144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/30/2023] [Indexed: 01/05/2024] Open
Abstract
Background Metronidazole treats obligate anaerobic bacterial and protozoal infections, with an elimination half-life of around 8 hours. The long elimination half-life, the favorable ratio of steady-state serum levels to minimum inhibitory concentration, and the presence of active metabolites have led to the consideration of metronidazole use at 12-hour dosage intervals. This systematic review aimed to compare the clinical outcomes of twice-daily and thrice-daily metronidazole dosing. Methods Using the PRISMA checklist, we searched five databases to systematically identify all relevant studies published up to June 16, 2023. Results The final analysis included two published retrospective cohort studies of hospitalized adult patients: a single site study (n = 200) and a multisite study (n = 85) of "good" quality, as measured by the Newcastle-Ottawa scale. The reported baseline characteristics of the 8-hour and 12-hour dosing groups were comparable, and neither study identified significant differences in primary and secondary clinical outcomes. Metaanalysis of the need to escalate antibiotic therapy also showed no statistically significant differences using the Mantel-Haenszel fixed-effect method (95% confidence interval: 47.6% lower to 6.4 times higher risk, P = 0.34) and inverse-variance method (risk ratio: 1.87; 95% confidence interval: 0.52-6.65, P = 0.34). Conclusions This review suggests that dosing metronidazole every 12 hours is as effective as every-8-hour dosing for hospitalized patients with anaerobic infections. These encouraging findings would benefit from validation by a multicenter randomized controlled trial since there would be many benefits to a 12-hour dosing interval while achieving similar clinical outcomes with traditional dosing. The studies in this systematic review excluded patients with Clostridioides difficile and central nervous system and amebiasis infections, so the findings do not apply to these infection types.
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Affiliation(s)
| | - Faran Ahmad
- Division of Infectious Disease, Pulmonary and Critical Care Medicine, Creighton University, Omaha, Nebraska, USA
| | - Ryan W. Walters
- Department of Clinical Research and Public Health, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Pamela A. Foral
- Creighton University School of Pharmacy, Omaha, Nebraska, USA
| | | | - Manasa Velagapudi
- Division of Infectious Disease, Creighton University School of Medicine, Omaha, Nebraska, USA
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McBee PJ, Larsen NK, Reilly MJ, Walters RW, Olson MA, Fitzgibbons RJ. Association of Nicotine Cessation Time on the Incidence of Recurrent Incisional Hernia Repair and Postoperative Surgical Site Occurrences. Am Surg 2023; 89:6127-6133. [PMID: 37501283 DOI: 10.1177/00031348231192042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
BACKGROUND Nicotine products are believed to be associated with a higher incidence of incisional hernia (IH) recurrence and postoperative complications after IH repair. METHODS A retrospective analysis of the Abdominal Core Health Quality Collaborative (ACHQC) database was performed. Outcomes included risk of IH recurrence, 30-day surgical site infection (SSI), and 30-day surgical site occurrence (SSO). RESULTS We included 14,663 patients. Nicotine users who quit within 1 year of surgery had a 26% higher risk of IH recurrence compared to patients who quit more than a year before surgery or never users. Patients who quit using nicotine within 1 year of surgery had a 54% higher odds of SSI compared to former nicotine users who quit more than a year before surgery. CONCLUSION Former nicotine users with less than 1 year of nicotine use cessation before surgery exhibited worse outcomes than those with more than a year of cessation or no prior use.
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Affiliation(s)
- Patrick J McBee
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Nicholas K Larsen
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Matthew J Reilly
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Ryan W Walters
- Department of Clinical Research, Creighton University School of Medicine, Omaha, NE, USA
| | - Molly A Olson
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
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Punja V, Capasso T, Stokes L, Ray K, Narveson JR, Walters RW, Fernandez C, Patel ND, Ewing K, Kuncir E. The Impact of Relocating a Trauma Center: Retrospective Observations on Payer Demographics and Cost-Analysis. Am Surg 2023; 89:5682-5689. [PMID: 37139931 DOI: 10.1177/00031348231175482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- Viren Punja
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Thomas Capasso
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Laura Stokes
- Creighton University School of Medicine, Omaha, NE, USA
| | - Kelley Ray
- Creighton University School of Medicine, Omaha, NE, USA
| | - Joel R Narveson
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE, USA
| | - Carlos Fernandez
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Neil D Patel
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Kaily Ewing
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Eric Kuncir
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
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Veatch JM, Narveson JR, Walters RW, Patel ND, Punja VP, Fernandez CA, Ewing KL, Aucar JA, Kuncir EJ. The Relationship Between an Individual's Birthday and Admission for Traumatic Injury. Am Surg 2023; 89:5750-5756. [PMID: 37147859 DOI: 10.1177/00031348231175456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
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.
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Affiliation(s)
- Jessica M Veatch
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Joel R Narveson
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE, USA
| | - Neil D Patel
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Viren P Punja
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Carlos A Fernandez
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Kaily L Ewing
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - John A Aucar
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Eric J Kuncir
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
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13
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Latif A, Tran AM, Ahsan MJ, Niu F, Walters RW, Kim MH. Relationship of health-related social needs and hospital readmissions in patients following a hospitalization for atrial fibrillation. Am Heart J Plus 2023; 36:100340. [PMID: 38510101 PMCID: PMC10946007 DOI: 10.1016/j.ahjo.2023.100340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/20/2023] [Accepted: 10/22/2023] [Indexed: 03/22/2024]
Abstract
Atrial fibrillation (AF) has a high economic burden on the healthcare system with rehospitalizations as the most significant contributing factor necessitating an understanding of aspects related to hospitalizations to minimize economic costs and improve patient outcomes. Our study aims to assess whether all-cause 30-day hospital readmission following AF-specific hospitalization is associated with health-related social needs (HRSN) using the Nationwide Readmissions Database (NRD). All hospitalization data were abstracted from the 2015-2019 NRD, including hospitalizations for patients at least 18 years of age with a primary discharge diagnosis of AF. For each hospitalization, we identified secondary diagnoses for five HRSN domains including employment, family, housing, psychosocial, and socioeconomic status. Primary outcomes included all-cause 30-day readmission rates. Secondary outcomes included all-cause 90-day readmissions and diagnosis on readmissions. An estimated 1,807,460 index hospitalizations in the United States included a primary discharge diagnosis of AF. Of these, 97.3 % included a diagnosis in only one HRSN domain with the most frequently diagnosed HRSN domain being housing (54.5 %) followed by socioeconomic (29.4 %), family (10.0 %), employment (6.1 %), and psychosocial (2.8 %). Index hospitalizations that included any HRSN diagnosis had 2.2-times greater unadjusted odds of all-cause 30-day readmission (95 % CI: 2.1 to 2.3-times greater, p < .001). Index hospitalizations that included an HRSN diagnosis were associated with higher rates of 90-day readmission due to conduction disorder and COPD. In conclusion, there is a significant association between HRSN and hospital readmissions in patients with AF. Further research is required to explain the true nature of this relationship with a specific emphasis on housing insecurity.
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Affiliation(s)
- Azka Latif
- Department of Cardiovascular Medicine, Baylor College of Medicine, Houston, TX, United States of America
| | - Amy M. Tran
- School of Medicine, Creighton University, Omaha, NE, United States of America
| | - Muhammad Junaid Ahsan
- Division of Cardiovascular Medicine, Iowa Heart Center, West Des Moines, IA, United States of America
| | - Fang Niu
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, United States of America
| | - Ryan W. Walters
- Department of Clinical Research and Public Health, Creighton University, Omaha, NE, United States of America
| | - Michael H. Kim
- Department of Medicine, Creighton University and CHI Health, Omaha, NE, United States of America
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14
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Dilsaver DB, Walters RW, Nandipati KC. Laparoscopic Heller Myotomy vs. Peroral Endoscopic Myotomy: an Analysis of the National Inpatient Sample Database. J Gastrointest Surg 2023; 27:2608-2610. [PMID: 37580486 DOI: 10.1007/s11605-023-05801-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/29/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Danielle B Dilsaver
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, Omaha, NE, USA
| | - Ryan W Walters
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, Omaha, NE, USA
| | - Kalyana C Nandipati
- Department of Surgery, School of Medicine, Creighton University, 7710 Mercy Road, Suite 501, Creighton University Education Bldg, Omaha, NE, 68124, USA.
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15
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Pajjuru VS, Warren BM, Daoud H, Radaideh Q, Walters RW, Alla VM. Impact of Center Procedural Volume on Mortality and Readmission Rates Following Pericardiectomy in the United States. Am J Cardiol 2023; 205:298-301. [PMID: 37633064 DOI: 10.1016/j.amjcard.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/29/2023] [Accepted: 08/05/2023] [Indexed: 08/28/2023]
Abstract
Our study aimed to explore the national trends in the rates of perioperative complications, in-hospital mortality, and readmissions after pericardiectomy and the impact of center volume on these outcomes. Using the Nationwide Readmission Database, we identified patients who underwent isolated pericardiectomy from 2010 to 2019. In-hospital mortality and readmission rates were assessed using orthogonal polynomial contrasts, with the linear and nonlinear trends evaluated as needed. Multivariable logistic regression models were constructed to identify the independent predictors of mortality and readmission. All analyses accounted for the Nationwide Readmission Database sampling design and were performed using SAS version 9.4 (SAS Institute Inc. Cary, NC.) with p <0.05 used to indicate statistical significance. A total of 26,169 hospitalizations for pericardiectomy were identified during the study period. The median age was 59 years and 44% were female. In-hospital mortality was 5.2%, and the median length of stay was 7 days. Advanced age, higher co-morbidity index, and lower annual facility pericardiectomy volume were independent predictors of in-hospital mortality. The 30- and 90-day readmission rates after pericardiectomy were 18% and 28%, respectively. Previous cardiac surgery, diagnosis of constrictive pericarditis, and greater co-morbidity score were independent predictors of readmission. In conclusion, isolated pericardiectomy rates have remained mostly constant, with relatively small changes in in-hospital mortality and 30- and 90-day readmission rates over the last decade. Advanced age, lower facility pericardiectomy volume, and higher Elixhauser co-morbidity index are independent predictors of surgical mortality.
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Affiliation(s)
- Venkata S Pajjuru
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska.
| | - Blair M Warren
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Hussein Daoud
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Qais Radaideh
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Ryan W Walters
- Department of Clinical Research and Public Health, Creighton University School of Medicine, Omaha, Nebraska
| | - Venkata M Alla
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
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16
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Klock JA, Bremer K, Niu F, Walters RW, Nandipati KC. Reply to Letter to the Editor Following "Robotic-Assisted Bariatric Surgery Is Associated with Increased Postoperative Complications Compared to Laparoscopic: a Nationwide Readmissions Database Study" by Klock et al. Obes Surg 2023; 33:3305-3306. [PMID: 37580522 DOI: 10.1007/s11695-023-06773-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Julie A Klock
- School of Medicine, Creighton University, Omaha, NE, USA
| | - Kristin Bremer
- Department of Surgery, School of Medicine, 7710 Mercy Road, Suite 501, Creighton University Education Bldg, Omaha, NE, 68124, USA
| | - Fang Niu
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ryan W Walters
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, Omaha, NE, USA
| | - Kalyana C Nandipati
- Department of Surgery, School of Medicine, 7710 Mercy Road, Suite 501, Creighton University Education Bldg, Omaha, NE, 68124, USA.
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17
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Palicherla A, Torres R, Walters RW, Thandra A, Narmi A, Smer A. Outcomes of Valvular Endocarditis in Patients With and Without Pericardial Effusion: A National Inpatient Sample Study. Curr Probl Cardiol 2023; 48:101863. [PMID: 37301489 DOI: 10.1016/j.cpcardiol.2023.101863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023]
Abstract
Over the last decade, hospitalizations for infective endocarditis (IE) have been steadily increasing, leading to a significant healthcare burden. Pericardial effusion (PCE) has been identified as a serious complication of IE, yet no significant association with mortality has been established. Our study aims to further analyze and understand the significance of PCE in patients with IE. We performed a retrospective analysis using the national inpatient sample database to identify all the hospital admissions with IE using ICD 10 codes and stratified them into 2 groups based on the presence of PCE. The outcomes of interest were inhospital mortality, inhospital complications, need for cardiac surgery, and length of stay. From 2015 Q4-2019, a total of 76,260 hospitalizations were included (weighted: 381,300), of which 2.7% included a PCE diagnosis. Hospitalizations with a PCE diagnosis included patients that were younger (51 vs 61, P < 0.001), as well as slightly more males (58.0% vs 55.2%, P = 0.011), and black patients (16.9% vs 12.9%, P < 0.001). PCE was associated with higher in-hospital death (12.7% vs 9.0%, P < 0.001), longer lengths of stay (12 days vs 7 days, P < 0.001), higher rates of cardiac surgery (22.4% vs 7.3%, P < 0.001). The rates of heart failure, heart block, renal failure, cardiogenic shock, and embolic stroke were higher on PCE group. We found that presence of PCE is associated with higher inhospital mortality, longer length of stay, and greater utilization of cardiac surgery, as well as presence of heart failure, heart block, cardiogenic shock, and embolic stroke.
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Affiliation(s)
- Anirudh Palicherla
- Department of Medicine, Creighton University School of Medicine, Omaha, NE.
| | - Rosa Torres
- Department of Medicine, Creighton University School of Medicine, Omaha, NE
| | - Ryan W Walters
- Department of Clinical Research and Public Health, Creighton University School of Medicine, Omaha, NE
| | - Abhishek Thandra
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, NE
| | - Ann Narmi
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, NE
| | - Aiman Smer
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, NE
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18
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Guddeti RR, Gill GS, Parekh JD, Jhand AS, Walters RW, Panaich SS, Goldsweig AM, Alla VM. Transcatheter Aortic Valve Implantation in Mixed Aortic Valve Disease: A Multicenter Study. Am J Cardiol 2023; 203:394-402. [PMID: 37517135 DOI: 10.1016/j.amjcard.2023.07.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/06/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023]
Abstract
Mixed aortic valve disease (MAVD), defined by the concurrent presence of aortic stenosis (AS) and insufficiency is frequently seen in patients who have undergone transcatheter aortic valve implantation (TAVI). However, studies comparing the outcomes of TAVI in MAVD versus isolated AS have demonstrated conflicting results. Therefore, we aim to assess the outcomes of TAVI in patients with MAVD in comparison with those with isolated severe AS. Patients who underwent native valve TAVI for severe AS at 3 tertiary care academic centers between January 2012 and December 2020 were included and categorized into 3 groups based on concomitant aortic insufficiency (AI) as follows: group 1, no AI; group 2, mild AI; and group 3, moderate to severe AI. Outcomes of interest included all-cause mortality and all-cause readmission rates at 30 days and 1 year. Other outcomes include bleeding, stroke, vascular complications, and the incidence of paravalvular leak at 30 days after the procedure. Of the 1,588 patients who underwent TAVI during the study period, 775 patients (49%) had isolated AS, 606 (38%) had mild AI, and 207 (13%) had moderate to severe AI. Society of Thoracic Surgeons risk scores were significantly different among the 3 groups (5% in group 1, 5.5% in group 2, and 6% in group 3, p = 0.003). Balloon-expandable valves were used in about 2/3 of the population. No statistically significant differences in 30-day or 1-year all-cause mortality and all-cause readmission rates were noted among the 3 groups. Post-TAVI paravalvular leak at follow-up was significantly lower in group 1 (2.3%) and group 2 (2%) compared with group 3 (5.6%) (p = 0.01). In summary, TAVI in MAVD is associated with comparable outcomes at 1 year compared with patients with isolated severe AS.
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Affiliation(s)
- Raviteja R Guddeti
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, Nebraska
| | - Gauravpal S Gill
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, Nebraska
| | - Jai D Parekh
- Division of Cardiovascular Diseases, University of Iowa, Iowa City, Iowa
| | - Aravdeep S Jhand
- Division of Cardiovascular Diseases, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ryan W Walters
- Department of Clinical Research, Creighton University School of Medicine, Omaha, Nebraska
| | - Sidakpal S Panaich
- Division of Cardiovascular Diseases, University of Iowa, Iowa City, Iowa
| | - Andrew M Goldsweig
- Division of Cardiovascular Diseases, University of Nebraska Medical Center, Omaha, Nebraska
| | - Venkata Mahesh Alla
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, Nebraska.
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19
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Ismayl M, Hussain Y, Aboeata A, Walters RW, Naidu SS, Messenger JC, Basir MB, Rao SV, Goldsweig AM, Altin SE. Pulmonary Artery Catheter Use and Outcomes in Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock Treated With Impella (a Nationwide Analysis from the United States). Am J Cardiol 2023; 203:304-314. [PMID: 37517125 DOI: 10.1016/j.amjcard.2023.06.117] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/24/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023]
Abstract
The role of continuous hemodynamic assessment with pulmonary artery (PA) catheter placement in cardiogenic shock (CS) remains debated. We aimed to assess the association between PA catheter placement and clinical outcomes in patients with CS secondary to ST-elevation myocardial infarction (STEMI) treated with an intravascular microaxial flow pump. We identified patients hospitalized with STEMI complicated by CS on mechanical circulatory support with an intravascular microaxial flow pump (Impella, Abiomed, Danvers, Massachusetts) using the National Inpatient Sample database and compared the outcomes in those treated with and without PA catheters. The primary outcome was in-hospital mortality. The secondary outcomes included in-hospital complications, hospital length of stay, inpatient costs, and temporal trends. The total cohort included 14,635 hospitalizations for STEMI complicated by CS treated with Impella between 2016 and 2020, of whom 5,505 (37.6%) received PA catheters. Over the study period, the use of PA catheters increased significantly from 25.9% to 41.8% (ptrend <0.01). Similarly, the use of Impella increased from 9.9% to 18.9% (ptrend <0.01). After adjustment for baseline characteristics using a multivariate logistic regression analysis, PA catheter use was associated with lower in-hospital mortality (adjusted odds ratio 0.80, 95% confidence interval 0.67 to 0.96, p = 0.01) and similar cardiovascular, neurologic, renal, and hematologic complications; length of stay; and inpatient costs compared with no PA catheter use. In conclusion, PA catheter use in patients with STEMI complicated by CS treated with Impella is associated with reduced in-hospital mortality and similar complication rates. Given the mortality benefit, further research is necessary to optimize PA catheter use in patients with STEMI with CS.
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Affiliation(s)
- Mahmoud Ismayl
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota.
| | - Yasin Hussain
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ahmed Aboeata
- Department of Cardiovascular Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Ryan W Walters
- Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, Nebraska
| | - Srihari S Naidu
- Department of Cardiovascular Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - John C Messenger
- Department of Cardiovascular Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Mir B Basir
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Sunil V Rao
- Department of Cardiovascular Medicine, NYU Langone Health System, New York, New York
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center and University of Massachusetts-Baystate, Springfield, Massachusetts
| | - S Elissa Altin
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
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20
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Klock JA, Bremer K, Niu F, Walters RW, Nandipati KC. Robotic-Assisted Bariatric Surgery Is Associated with Increased Postoperative Complications Compared to Laparoscopic: a Nationwide Readmissions Database Study. Obes Surg 2023; 33:2186-2193. [PMID: 37219675 DOI: 10.1007/s11695-023-06657-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/11/2023] [Accepted: 05/17/2023] [Indexed: 05/24/2023]
Abstract
PURPOSE Robotic-assisted (RA) bariatric surgery has been increasingly used without consistent benefit over a laparoscopic approach (LA). We compared intra- and post-operative complications and 30- and 90-day all-cause readmissions between RA and LA using the Nationwide Readmissions Database (NRD). MATERIALS AND METHODS We identified hospitalizations with adult patients who underwent RA or LA bariatric surgery from 2010 to 2019. Primary outcomes included intra- and post-operative complications and 30- and 90-day all-cause readmissions. Secondary outcomes included in-hospital death, length of stay (LOS), cost, and cause-specific readmissions. Multivariable regression models were estimated; analyses accounted for the NRD sampling design. RESULTS A total of 1,371,778 hospitalizations met inclusion criteria with 7.1% using RA. Patient demographic and clinical characteristics were mostly similar between groups. Adjusted odds of complication were 13% higher for RA (adjusted odds ratio [aOR]: 1.13, 95% CI: 1.03-1.23 p = .008); aORs differed across bariatric procedures. The most common complications included nausea/vomiting, acute blood loss anemia, incisional hernia, and transfusion. Adjusted odds of 30- and 90-day readmission were 10% higher for RA (aOR: 1.10, 95% CI: 1.04-1.17, p = .001 and aOR: 1.10, 95% CI: 1.04-1.16, p <.001, respectively). LOS was similar (1.6 vs. 1.6 days, p = .253); although, hospital costs were 31.1% higher for RA ($15,806 vs. $12,056, p < .001). CONCLUSION RA bariatric surgery is associated with 13% higher odds of complication, 10% higher odds of readmission, and 31% hospital costs. Subsequent studies are required using databases that can include additional patient-, facility-, surgery-, and surgeon-specific characteristics.
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Affiliation(s)
- Julie A Klock
- School of Medicine, Creighton University, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Kristin Bremer
- Department of Surgery, School of Medicine, Creighton University, 7710 Mercy Road, Education Building, Suite 501, Omaha, NE, 68124, USA
| | - Fang Niu
- Department of Biostatistics, UNMC College of Public Health, 984375 Nebraska Medical Center, Omaha, NE, 68197, USA
| | - Ryan W Walters
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, 7710 Mercy Road, Education Building, Suite 502, Omaha, NE, 68124, USA
| | - Kalyana C Nandipati
- Department of Surgery, School of Medicine, Creighton University, 7710 Mercy Road, Education Building, Suite 501, Omaha, NE, 68124, USA.
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Satish M, Walters RW, Alla VM, Halperin JL. Association Between Stable Coronary Artery Disease and Hospital Readmissions Following Catheter Ablation for Atrial Fibrillation. Mayo Clin Proc 2023:S0025-6196(23)00014-9. [PMID: 37125976 DOI: 10.1016/j.mayocp.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 11/15/2022] [Accepted: 01/10/2023] [Indexed: 05/02/2023]
Abstract
OBJECTIVE To evaluate the association of stable coronary artery disease (CAD) with readmission following hospitalization for catheter ablation (CA) for atrial fibrillation (AF). PATIENTS AND METHODS Using the Nationwide Readmissions Database, we identified all hospitalizations from the last quarter of 2015 through 2019 with a Medicare Severity-Diagnosis Related Group designation for a percutaneous intracardiac procedure, a procedure code for CA, and a primary discharge diagnosis of AF. Cases of acute coronary syndrome (ACS) at index hospitalization were excluded to define stable CAD. The primary outcome was all-cause 90-day hospital readmission; secondary end points included readmissions for AF, repeated CA, ACS, and heart failure (HF). RESULTS Among 28,466 hospitalizations for CA for AF identified, 3171 (11.1%) involved patients with stable CAD. No hospitalizations included patients with HF diagnosis codes. The incidence of 90-day all-cause readmission was higher in patients with stable CAD (18.4% [400 of 2172] vs 14.4% [2549 of 17,667]; P=.006), as was the incidence of subsequent hospitalization with ACS (5.3% [21] vs 1.1% [28]; P<.001) or HF (17.0% [68] vs 10.2% [260]; P=.007). The incidence of readmission within 90 days with recurrent AF did not differ for those with or without stable CAD (21.9% [88] vs 26.5% [675]; P=.217). Pooled analysis of 90-day HF readmissions revealed a higher incidence among older patients, those with chronic kidney or pulmonary disease, and those with persistent and chronic AF subtypes. CONCLUSION Results of this large-scale analysis suggest that among patients hospitalized for CA for AF, stable CAD is associated with hospital readmissions within 90 days, including admissions for ACS and decompensated HF.
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Affiliation(s)
- Mohan Satish
- Icahn School of Medicine at Mount Sinai, New York, NY
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22
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Ismayl M, Abbasi MA, Al-Abcha A, El-Am E, Walters RW, Goldsweig AM, Alkhouli M, Guerrero M, Anavekar NS. Racial and Ethnic Disparities in the Use and Outcomes of Transcatheter Mitral Valve Replacement: Analysis From the National Inpatient Sample Database. J Am Heart Assoc 2023; 12:e028999. [PMID: 36974752 PMCID: PMC10122911 DOI: 10.1161/jaha.122.028999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Background Racial and ethnic disparities in outcomes exist following many cardiac procedures. Transcatheter mitral valve replacement (TMVR) has grown as an alternative to mitral valve surgery for patients at high surgical risk. The outcomes of TMVR by race and ethnicity are unknown. We aimed to evaluate racial and ethnic disparities in the outcomes of TMVR. Methods and Results We analyzed the National Inpatient Sample database from 2016 to 2020 to identify hospitalizations for TMVR. Racial and ethnic disparities in TMVR outcomes were determined using logistic regression models. Between 2016 and 2020, 5005 hospitalizations for TMVR were identified, composed of 3840 (76.7%) White race, 505 (10.1%) Black race, 315 (6.3%) Hispanic ethnicity, and 345 (6.9%) from other races (Asian, Pacific Islander, American Indian or Alaska Native, Other). Compared with other racial and ethnic groups, Black patients were significantly younger and more likely to be women (both P<0.01). There were no significant differences between White, Black, and Hispanic patients in in-hospital mortality (5.2% versus 5.0% versus <3.5%; P=0.89) and procedural complications, including heart block (P=0.91), permanent pacemaker (P=0.49), prosthetic valve dysfunction (P=0.45), stroke (P=0.37), acute kidney injury (P=0.32), major bleeding (P=0.23), and blood transfusion (P=0.92), even after adjustment for baseline characteristics. Adjusted vascular complications were higher in Black compared with White patients (P=0.03). Trend analysis revealed a significant increase in TMVR in all racial and ethnic groups from 2016 to 2020 (Ptrend<0.05). Conclusions Between 2016 and 2020, Black and Hispanic patients undergoing TMVR had similar in-hospital outcomes compared with White patients, except for higher vascular complications in Black patients. Further comparative studies of TMVR in clinically similar White patients and other racial and ethnic groups are warranted to confirm our findings.
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Affiliation(s)
- Mahmoud Ismayl
- Department of Internal Medicine Creighton University School of Medicine Omaha NE
| | | | | | - Edward El-Am
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Ryan W Walters
- Department of Clinical Research and Evaluative Sciences Creighton University School of Medicine Omaha NE
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine Baystate Medical Center Springfield MA
| | | | - Mayra Guerrero
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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Coté JJ, Côté-Arsenault D, Handelzalts JE, Badura-Brack AS, Kalata M, Walters RW, Kasinath P, Kump DA, Herbig K, Tampi R. Effects of 3D-Printed Models and 3D Printed Pictures on Maternal- and Paternal-Fetal Attachment, Anxiety, and Depression. J Obstet Gynecol Neonatal Nurs 2023; 52:223-234. [PMID: 36940782 DOI: 10.1016/j.jogn.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/19/2023] Open
Abstract
OBJECTIVE To compare the effect of a 3D-printed model versus 3D printed pictures on maternal- and paternal-fetal attachment, pregnancy-related anxiety, and depression in parents in the third trimester. DESIGN Randomized controlled trial. SETTING University- and clinic-affiliated hospital system. PARTICIPANTS Between August 2020 and July 2021, we screened 419 women for eligibility. A total of 184 participants (n = 95 women and n = 89 men) were included in the intention-to-treat analysis, of whom 47 women and 44 men received the 3D-printed model, whereas 48 women and 45 men received the 3D printed picture. METHODS Participants completed a set of questionnaires before they received third trimester 3D ultrasonography and a second set of questionnaires approximately 14 days after the study ultrasonography. The primary outcome was the global Maternal and Paternal Antenatal Attachment scale scores. Secondary outcomes included the Maternal and Paternal Antenatal Attachment subscale scores, global Generalized Anxiety Disorder-7 scores, global Patient Health Questionnaire-9 scores, and global Pregnancy-Related Anxiety Questionnaire-Revised (second version) scores. We used multilevel models to estimate the effect of the intervention. RESULTS We found a statistically significant increase in mean attachment scores after the 3D printed picture and 3D-printed model intervention of 0.26, 95% confidence interval (CI) [0.22, 0.31], p < .001. Additionally, we found statistically significant improvement in depression (mean change = -1.08, 95% CI [-1.54, -0.62], p < .001), anxiety (mean change = -1.38, 95% CI [-1.87, -0.89], p < .001), and pregnancy-related anxiety (mean change = -2.92, 95% CI [-4.11, -1.72], p < .001) scores. We found no statistically significant between-group differences related to maternal or paternal attachment, anxiety, depression, or pregnancy-related anxiety. CONCLUSIONS Our findings support the use of 3D printed pictures and 3D-printed models to improve prenatal attachment, anxiety, depression, and pregnancy-related anxiety.
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24
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Thandra A, Balakrishna AM, Walters RW, Alugubelli N, Koripalli VS, Alla VM. Trends in and predictors of multiple readmissions following heart failure hospitalization: A National wide analysis from the United States. Am J Med Sci 2023; 365:145-151. [PMID: 36152813 DOI: 10.1016/j.amjms.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 05/23/2022] [Accepted: 09/12/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND 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). METHODS 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 p < 0.05 used to indicate statistical significance. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Abhishek Thandra
- Department of Medicine, Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, United States.
| | | | - Ryan W Walters
- Department of Medicine, Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE, United States
| | - Navya Alugubelli
- Department of Medicine, Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, United States
| | | | - Venkata M Alla
- Department of Medicine, Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, United States
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25
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Jagan N, Morrow LE, Walters RW, Plambeck RW, Ng I, Chovatiya JJ, Macaraeg JC, Kalian KF, Wittenberg ZL, Pruett WM, Knedler J, Klein LP, Kasinath P, Dyer ED, Bergh AA, Malesker MA. A Retrospective Analysis of the Effects of Time on Compliance and Driving Pressures in ARDS. Respir Care 2023; 68:52-59. [PMID: 35705249 PMCID: PMC9993514 DOI: 10.4187/respcare.10080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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 (P = .24), whereas COVID-19-negative subjects who were either culture positive or negative showed statistically significant improvement (0.12 and 0.18, respectively; both P < .05); a statistically similar but inverse pattern was observed for driving pressure. CONCLUSIONS 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.
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Affiliation(s)
- Nikhil Jagan
- Creighton University School of Medicine, Division of Pulmonary and Critical Care, Omaha, Nebraska.
| | - Lee E Morrow
- Creighton University School of Medicine, Division of Pulmonary and Critical Care, Omaha, Nebraska
| | - Ryan W Walters
- Creighton University School of Medicine, Department of Clinical Research, Omaha, Nebraska
| | - Robert W Plambeck
- Creighton University School of Medicine, Division of Pulmonary and Critical Care, Omaha, Nebraska
| | - Ian Ng
- Creighton University School of Medicine, Department of Clinical Research, Omaha, Nebraska
| | - Jasmin J Chovatiya
- Creighton University School of Medicine, Department of Internal Medicine, Omaha, Nebraska
| | - Jeffrey C Macaraeg
- Creighton University School of Medicine, Division of Pulmonary and Critical Care, Omaha, Nebraska
| | - Karson F Kalian
- Creighton University School of Medicine, Division of Pulmonary and Critical Care, Omaha, Nebraska
| | - Zachariah L Wittenberg
- Creighton University School of Medicine, Division of Pulmonary and Critical Care, Omaha, Nebraska
| | - William M Pruett
- Creighton University School of Medicine, Division of Pulmonary and Critical Care, Omaha, Nebraska
| | - Jonathan Knedler
- CHI Health, Division of Pulmonary and Critical Care, Omaha, Nebraska
| | - Lauren P Klein
- CHI Health, Division of Pulmonary and Critical Care, Omaha, Nebraska
| | - Pooja Kasinath
- Creighton University School of Medicine, Omaha, Nebraska
| | - Emily D Dyer
- Creighton University School of Medicine, Department of Internal Medicine, Omaha, Nebraska
| | - Adam A Bergh
- Creighton University School of Medicine, Omaha, Nebraska
| | - Mark A Malesker
- Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska; and Creighton University School of Medicine, Division of Pulmonary and Critical Care, Omaha, Nebraska
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Vitek G, Langenfeld R, Walters RW, Elson A, Driscoll D, Ramaswamy S. Therapeutic and Safety Outcomes of Intravenous Ketamine for Treatment-refractory Depression in a Veteran Population: A Case Series. Mil Med 2022; 188:usac395. [PMID: 36539918 DOI: 10.1093/milmed/usac395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/05/2022] [Accepted: 11/29/2022] [Indexed: 02/17/2024] Open
Abstract
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 < .05 indicating the statistical significance. This study had institutional review board approval: 1220. 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 < .001), but the strongest reduction occurred before day 40. The change was statistically significant for decreased heart rate (P = .019) but not for systolic blood pressure (P = .612), diastolic blood pressure (P = .942), respiratory rate (P = .822), oxygen saturation (P = .070), and temperature (P = .943). Side effects were reported in six patients (75%); however, the only side effect reported was excessive sedation or dizziness immediately after infusion. 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.
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Affiliation(s)
- Grace Vitek
- Creighton University School of Medicine, Omaha, NE 68178, USA
| | | | - Ryan W Walters
- Creighton University School of Medicine, Omaha, NE 68178, USA
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Klock JA, Walters RW, Nandipati KC. Robotic Hiatal Hernia Repair Associated with Higher Morbidity and Readmission Rates Compared to Laparoscopic Repair: 10-Year Analysis from the National Readmissions Database (NRD). J Gastrointest Surg 2022; 27:489-497. [PMID: 36508133 DOI: 10.1007/s11605-022-05548-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/13/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Laparoscopic techniques have been used for hiatal hernia repair. Robotic-assisted repairs have been increasingly used with unproven benefits. The aim of this study was to compare outcomes between laparoscopic and robotic-assisted hiatal hernia repair. METHODS The Nationwide Readmissions Database (NRD) was used to identify hospitalizations for laparoscopic or robotic hiatal hernia repair from 2010 to 2019. Primary outcomes included post-operative complications and 30- and 90-day readmission rates. Secondary outcomes included in-hospital death, length of stay, and inflation-adjusted hospital cost. Multivariable models were estimated for overall complication and readmission rates. RESULTS Approximately 517,864 hospitalizations met inclusion criteria with 11.3% including robotic repairs. Robotic repair was associated with a higher overall complication rate (9.2% vs. 6.8%, odds ratio [OR]: 1.4, 95% CI: 1.3-1.5, p < .001); however, the trend showed more similar complication rates across years. The higher overall complication rate remained after adjusting for patient and facility characteristics (adjusted OR [aOR]: 1.3, 95% CI: 1.2-1.4, p < .001). Robotic repairs were associated with higher 30-day (6.1% vs. 7.4%, aOR: 1.2, 95% CI: 1.2-1.3, p < .001) and 90-day readmission rates (9.4% vs. 11.2%, aOR: 1.2, 95% CI: 1.2-1.3, p < .001). In-hospital mortality and length of stay were similar, although, higher hospital costs were associated with robotic repairs. Both complications and readmission rates were lower as annual procedural volume increased. CONCLUSION Robotic repairs had higher unadjusted and adjusted complication and readmission rates. The overall complication rate has shown a trend towards improvement which may be a result of increasing experience with robotic surgery.
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Affiliation(s)
- Julie A Klock
- School of Medicine, Creighton University, Omaha, NE, USA
| | - Ryan W Walters
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, Omaha, NE, USA
| | - Kalyana C Nandipati
- Department of Surgery, School of Medicine, Creighton University, Education Bldg., 7710 Mercy Road, Suite 501, Omaha, NE, 68124, USA.
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28
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Nuttall E, Ives S, White A, Gallagher K, Pynes R, Walters RW, Varman M. Information Sources and Attitudes Toward COVID-19 Vaccination at a Free Clinic in the State of Nebraska, USA. J Community Health 2022; 48:252-259. [PMID: 36371773 PMCID: PMC9660115 DOI: 10.1007/s10900-022-01158-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Elle Nuttall
- Creighton University School of Medicine, Criss Health Sciences Complex II, 2621 Burt Street, 2500 California Plaza, Omaha, NE, 68178, USA.
| | - Sarah Ives
- Creighton University School of Medicine, Criss Health Sciences Complex II, 2621 Burt Street, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Anna White
- Creighton University School of Medicine, Criss Health Sciences Complex II, 2621 Burt Street, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Kiara Gallagher
- Creighton University School of Medicine, Criss Health Sciences Complex II, 2621 Burt Street, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Rosemary Pynes
- Creighton University School of Medicine, Criss Health Sciences Complex II, 2621 Burt Street, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Ryan W Walters
- Department of Clinical Research and Public Health, Creighton University School of Medicine, 7710 Mercy Road, Suite 502, Omaha, NE, 68124, USA
| | - Meera Varman
- Department of Pediatrics, Creighton University School of Medicine, 7710 Mercy Road, Suite 602, Omaha, NE, 68124, USA
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29
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Fernandez CA, Narveson JR, Walters RW, Patel ND, Veatch JM, Ewing KL, Capasso TJ, Punja VP, Kuncir EJ. Takotsubo Cardiomyopathy and Trauma: The Role of Injuries as Physical Stressors. Cureus 2022; 14:e27411. [PMID: 36046294 PMCID: PMC9418767 DOI: 10.7759/cureus.27411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/05/2022] Open
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30
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Luizzi AB, Le AV, Gill GS, Walters RW, Del Core M. Medical versus invasive management of non-ST segment elevation myocardial infarction in diabetes mellitus. Cardiovasc Revasc Med 2022; 44:32-36. [PMID: 35840457 DOI: 10.1016/j.carrev.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Alexander B Luizzi
- School of Medicine, Creighton University, Omaha, NE, United States of America
| | - Austin V Le
- School of Medicine, Creighton University, Omaha, NE, United States of America.
| | - Gauravpal S Gill
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE, United States of America
| | - Ryan W Walters
- Department of Clinical Research, School of Medicine, Creighton University, Omaha, NE, United States of America
| | - Michael Del Core
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE, United States of America
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31
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Kousa O, Addasi Y, Machanahalli Balakrishna A, Pajjuru VSK, Bardwell JK, Walters RW, Ponamgi S, Alla VM. Elevated troponin in patients with acute gastrointestinal bleeding: prevalence, predictors and outcomes. Future Cardiol 2022; 18:709-717. [PMID: 35770979 DOI: 10.2217/fca-2021-0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Cardiac troponin (cTn) can also be elevated in patients with non-cardiac illnesses. The utility of elevated cTn in patients with acute gastrointestinal bleeding (AGIB) is unclear. Methods: We retrospectively identified all patients admitted with AGIB who had cTn ordered. We assessed the prevalence, predictors and mortality. Results: A total of 172 patients with AGIB were included in the study, of whom 17% had abnormal cTn. Predictors of elevated cTn were advanced age, lower BMI, coronary artery disease and chronic kidney disease. The abnormal cTn group had more cardiac consultation and procedures and longer length of stay. However, there was no difference in mortality between the two groups. Conclusion: Elevated cTn in patients with AGIB was associated with more cardiology consultation and downstream cardiac testing, greater delay to endoscopic evaluation and longer length of stay, without significantly affecting the mortality.
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Affiliation(s)
- Omar Kousa
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska, NE 68124, USA
| | - Yazan Addasi
- Department of Internal Medicine, Creighton UniversitySchool of Medicine, Omaha, Nebraska, NE 68124, USA
| | | | | | - Josiah K Bardwell
- Department of Internal Medicine, Creighton UniversitySchool of Medicine, Omaha, Nebraska, NE 68124, USA
| | - Ryan W Walters
- Department of Clinical Research, Creighton University School of Medicine, Omaha, Nebraska, NE 68124, USA
| | - Shiva Ponamgi
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska, NE 68124, USA
| | - Venkata Mahesh Alla
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska, NE 68124, USA
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32
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Ismayl M, Machanahalli Balakrishna A, Walters RW, Pajjuru VS, Goldsweig AM, Aboeata A. In-hospital mortality and readmission after ST-elevation myocardial infarction in nonagenarians: A nationwide analysis from the United States. Catheter Cardiovasc Interv 2022; 100:5-16. [PMID: 35568973 DOI: 10.1002/ccd.30227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 04/14/2022] [Accepted: 05/03/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To assess readmission rates in nonagenarians (age ≥ 90 years) with ST-elevation myocardial infarction (STEMI) following primary percutaneous coronary intervention (pPCI) versus no pPCI. BACKGROUND There are limited data exploring readmissions following STEMI in nonagenarians undergoing pPCI versus no pPCI. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Mahmoud Ismayl
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | | | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Venkata S Pajjuru
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Andrew M Goldsweig
- Division of Cardiology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ahmed Aboeata
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
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Abstract
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 < 0.001). 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.
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Affiliation(s)
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, 12282Creighton University School of Medicine, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Sriram Ramaswamy
- Department of Psychiatry, Creighton University School of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Venkata M Alla
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
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Abstract
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.
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Affiliation(s)
- Jennifer M. Burgart
- Department of Obstetrics and Gynecology, Creighton University, Omaha, Nebraska, USA.,Address correspondence to: Jennifer M. Burgart, MD, MS, Department of Obstetrics and Gynecology, Creighton University, Omaha, NE 68124, USA,
| | - Ryan W. Walters
- Division of Clinical Research and Evaluative Sciences, Department of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Meaghan Shanahan
- Department of Obstetrics and Gynecology, Creighton University, Omaha, Nebraska, USA
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Abstract
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.
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Affiliation(s)
- Lesa Hoffman
- Department of Psychological and Quantitative Foundations, University of Iowa, Iowa City, Iowa 52242, USA
| | - Ryan W. Walters
- Department of Clinical Research, Creighton University, Omaha, Nebraska 68178, USA
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Pajjuru VS, Thandra A, Walters RW, Papudesi BN, Aboeata A, Vallabhajosyula S, Altin SE, Sutton NR, Alla VM, Goldsweig AM. Sex disparities in in-hospital outcomes of left ventricular aneurysm complicating acute myocardial infarction: A United States nationwide analysis. Am Heart J Plus 2022; 13:100104. [PMID: 38560084 PMCID: PMC10978193 DOI: 10.1016/j.ahjo.2022.100104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 04/04/2024]
Abstract
Background Previous studies have reported sex-specific differences in the presentation, mechanisms, and outcomes of acute myocardial infarction (AMI). We assessed differences between women and men in the incidence and in-hospital outcomes of left ventricular (LV) aneurysm complicating AMI. Methods Hospitalizations for AMI with LV aneurysm were identified retrospectively in the National Inpatient Sample (NIS) from 2001 to 2017. Incidence and trends in in-hospital mortality, complications, length of stay and costs were analyzed in women and men. Results A total of 16,334 AMI hospitalizations with concomitant LV aneurysm were identified including 6994 (42.8%) women and 9340 (57.2%) men. Among these hospitalizations, women had a higher incidence of LV aneurysm compared to men (0.16% vs. 0.14%; p < 0.001). Unadjusted in-hospital mortality was higher in women than men (12.7% vs. 7.2%; p < 0.001). After adjusting for demographic and baseline characteristics and excluding inter-hospital transfers, women with AMI complicated by LV aneurysm had 49% greater odds of in-hospital mortality than men (OR 1.49, 95% confidence interval 1.06-2.10, p = 0.02). Women with LV aneurysm were less likely than men to undergo percutaneous coronary intervention (28.5% vs. 35.4%; p < 0.001), bypass surgery (15.8% vs. 25.1%; p < 0.001), coronary atherectomy (0.8% vs. 1.9%; p = 0.009) and LV aneurysm surgery (7.8% vs. 11.1%; p = 0.001). Conclusions In this large population-based cohort study, women had a slightly higher incidence but dramatically higher in-hospital mortality associated with LV aneurysm complicating AMI compared to men. Further research is necessary to validate strategies to ensure that women receive guideline-directed therapy for AMI and LV aneurysm to address the sex disparity in mortality.
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Affiliation(s)
- Venkata S. Pajjuru
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Abhishek Thandra
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Ryan W. Walters
- Division of Clinical Research and Evaluative Sciences, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | | | - Ahmed Aboeata
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - S. Elissa Altin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Nadia R. Sutton
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Venkata M. Alla
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Andrew M. Goldsweig
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Reid E, Walters RW, Destache CJ. Beta-Lactam vs. Fluoroquinolone Monotherapy for Pseudomonas aeruginosa Infection: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2021; 10:antibiotics10121483. [PMID: 34943695 PMCID: PMC8698261 DOI: 10.3390/antibiotics10121483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Pseudomonas aeruginosa (PA) is a leading cause of healthcare-associated infections. A variety of antibiotic classes are used in the treatment of PA infections, including beta-lactams (BLs) and fluoroquinolones (FQs), given either together in combination therapy or alone in monotherapy. A systematic review and meta-analysis were performed to evaluate the therapeutic efficacy of BL agents versus FQ agents as active, definitive monotherapy in PA infections in adults. Methods: Comprehensive literature searches of the Medline and Scopus electronic databases, alongside hand searches of the Cochrane Database of Systematic Reviews, PubMed, and Google Scholar, were performed without a time restriction to identify studies published in English comparing BL and FQ agents given as monotherapy for PA infection in hospitalized adults for which mortality, bacteriological eradication, or clinical response was evaluated. One reviewer screened search results based on pre-defined selection criteria. Two reviewers independently assessed included studies for methodological quality using NIH assessment tools. Two fixed-effects meta-analyses were performed. Results: A total of 368 articles were screened, and six studies involving 338 total patients were included in the meta-analysis. Upon evaluation of methodological quality, two studies were rated good, three fair, and one poor. A meta-analysis of three studies demonstrates FQ monotherapy is associated with significantly improved survival compared to BL monotherapy for patients with PA bacteremia (OR, 3.65; 95% CI, 1.27–10.44; p = 0.02). A meta-analysis of three studies demonstrates FQ monotherapy is associated with equivalent bacteriological eradication compared to BL monotherapy for PA pneumonia or skin and soft tissue infection (RD, 0.07; 95% CI, −0.09 to 0.24; p = 0.39). Conclusion: The meta-analyses demonstrate FQ monotherapy significantly improves survival in PA bacteremia and is associated with similar rates of bacteriological eradication in pneumonia and skin and soft tissue infection caused by PA compared to BL monotherapy. However, more research is needed to make meaningful clinical recommendations.
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Affiliation(s)
- Eric Reid
- School of Medicine, Creighton University, Omaha, NE 68178, USA; (R.W.W.); (C.J.D.)
- Correspondence:
| | - Ryan W. Walters
- School of Medicine, Creighton University, Omaha, NE 68178, USA; (R.W.W.); (C.J.D.)
| | - Christopher J. Destache
- School of Medicine, Creighton University, Omaha, NE 68178, USA; (R.W.W.); (C.J.D.)
- School of Pharmacy & Health Professions, Creighton University, Omaha, NE 68178, USA
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Shaikh KA, Walters RW, Aboeata A, Thandra A, Anugula D, Urja P, Alla VM, Budoff MJ. Trends in utilization of Coronary CT Angiography in patients presenting with acute chest pain in United States: An analysis of the National Emergency Database. J Cardiovasc Comput Tomogr 2021; 16:277-278. [PMID: 34844899 DOI: 10.1016/j.jcct.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Kashif A Shaikh
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA; Harbor-UCLA Medical Center, Department of Internal Medicine, Division of Cardiology, USA.
| | - Ryan W Walters
- Creighton University School of Medicine, Department of Medicine, Division of Clinical Research and Evaluative Sciences, USA
| | - Ahmed Aboeata
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA
| | - Abhishek Thandra
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA
| | - Dixitha Anugula
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA
| | - Prakrity Urja
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA
| | - Venkata M Alla
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA
| | - Matthew J Budoff
- Harbor-UCLA Medical Center, Department of Internal Medicine, Division of Cardiology, USA
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Guddeti RR, Pajjuru VS, Walters RW, Garcia SA, Alla VM. Impact of gender on in-hospital mortality and 90-day readmissions in patients undergoing transcatheter edge-to-edge mitral valve repair: Analysis from the National Readmission Database. Catheter Cardiovasc Interv 2021; 98:E954-E962. [PMID: 34343407 DOI: 10.1002/ccd.29887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/07/2021] [Accepted: 07/16/2021] [Indexed: 11/11/2022]
Abstract
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 < 0.001 and 28.1% vs. 23.9%; p = 0.020 respectively). In a multivariable analysis, women had 36% greater odds of 90-day readmission compared to men (adjusted odds ratio [aOR] 1.36, 95% CI: 1.22-1.52; p < 0.001). Trend analysis revealed no significant improvement in rates of 90-day readmission during the observation period for men or women (p = 0.245, p = 0.429, respectively). CONCLUSIONS Following TEER, there has been no significant improvement in 90-day readmission rates between 2012 and 2018. Female gender is associated with higher 90-day all-cause and heart failure readmission rates.
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Affiliation(s)
- Raviteja R Guddeti
- Division of Interventional Cardiology, Minneapolis Heart Institute/Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Venkata S Pajjuru
- Division of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Ryan W Walters
- Department of Clinical Research, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Santiago A Garcia
- Division of Interventional Cardiology, Minneapolis Heart Institute/Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Venkata M Alla
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, Nebraska, USA
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Block AJ, Shikiya RA, Eckland TE, Kincaid AE, Walters RW, Ma J, Bartz JC. Efficient interspecies transmission of synthetic prions. PLoS Pathog 2021; 17:e1009765. [PMID: 34260664 PMCID: PMC8312972 DOI: 10.1371/journal.ppat.1009765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/26/2021] [Accepted: 06/29/2021] [Indexed: 11/18/2022] Open
Abstract
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. 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.
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Affiliation(s)
- Alyssa J. Block
- Department of Medical Microbiology and Immunology, Creighton University, Omaha, Nebraska, United States of America
| | - Ronald A. Shikiya
- Department of Medical Microbiology and Immunology, Creighton University, Omaha, Nebraska, United States of America
| | - Thomas E. Eckland
- Department of Medical Microbiology and Immunology, Creighton University, Omaha, Nebraska, United States of America
| | - Anthony E. Kincaid
- Department of Pharmacy Science, Creighton University, Omaha, Nebraska, United States of America
| | - Ryan W. Walters
- Department of Medicine, Creighton University, Omaha, Nebraska, United States of America
| | - Jiyan Ma
- Van Andel Institute, Center for Neurodegenerative Science, Grand Rapids, Michigan, United States of America
| | - Jason C. Bartz
- Department of Medical Microbiology and Immunology, Creighton University, Omaha, Nebraska, United States of America
- * E-mail:
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Stewart NH, Walters RW, Mokhlesi B, Lauderdale DS, Arora VM. Sleep in hospitalized patients with chronic obstructive pulmonary disease: an observational study. J Clin Sleep Med 2021; 16:1693-1699. [PMID: 32620186 DOI: 10.5664/jcsm.8646] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
STUDY OBJECTIVES The aim of this study was to compare the risk of undiagnosed sleep disorders among medical patients with chronic obstructive pulmonary disease (COPD) compared with those without COPD. METHODS In a prospective cohort study, hospitalized medical ward patients without a known sleep disorder were screened, using validated questionnaires, for sleep disorders, such as obstructive sleep apnea and insomnia. Daily sleep duration and efficiency in the hospital were measured via wrist actigraphy. Participants were classified into two groups: those with a primary or secondary diagnosis of COPD and those without a history of COPD diagnosis. Sleep outcomes were compared by COPD diagnosis. RESULTS From March 2010 to July 2015, 572 patients completed questionnaires and underwent wrist actigraphy. On admission, patients with COPD had a greater adjusted risk of obstructive sleep apnea (adjusted odds ratio 1.82, 95% confidence interval 1.12-2.96, P = .015) and clinically significant insomnia (adjusted odds ratio 2.07, 95% confidence interval 1.12-3.83, P = .021); no differences were observed for sleep quality or excess sleepiness on admission. After adjustment, compared with patients without COPD, patients with COPD averaged 34 fewer minutes of nightly sleep (95% confidence interval 4.2-64.0 minutes, P = .026), as well as 22.5% lower odds of normal sleep efficiency while in the hospital (95% confidence interval 3.3%-37.9%, P = .024). No statistically significant differences were observed for in-hospital sleep quality, soundness, or ease of falling asleep. CONCLUSIONS Among hospitalized patients in medical wards, those with COPD have higher risk of OSA and insomnia and worse in-hospital sleep quality and quantity compared with those without COPD.
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Affiliation(s)
- Nancy H Stewart
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Ryan W Walters
- Department of Medicine, Creighton University, Omaha, Nebraska
| | - Babak Mokhlesi
- Section of Pulmonary, Critical Care, and Sleep Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Diane S Lauderdale
- Department of Public Health Studies, University of Chicago, Chicago, Illinois
| | - Vineet M Arora
- Section of General Internal Medicine, University of Chicago Medical Center, Chicago, Illinois
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Abstract
Background Renin‐angiotensin system blockers (RASBs) have well‐validated benefit in patients with hypertension, coronary artery disease, and left ventricular systolic dysfunction. Their use in the perioperative period, however, has been controversial, including in patients undergoing cardiac surgery, who often have a strong indication for their use. In the current study, we explore the impact of RASB use with 30‐day and 1‐year mortality after cardiac surgery. Methods and Results The Veterans Affairs Surgical Quality Improvement Program and Corporate Data Warehouse were data sources for this retrospective cohort study. A total of 37 197 veterans undergoing elective coronary artery bypass grafting and or valve repair or replacement over a 10‐year period met inclusion criteria and were stratified into 4 groups by preoperative exposure (preoperative exposure versus no preoperative exposure) and postoperative continuing exposure (current exposure versus no current exposure) to RASBs. After adjusting for all baseline covariates, the preoperative exposure/current exposure group had lower 30‐day and 1‐year mortality than the preoperative exposure/no current exposure (30‐day hazard ratio [HR], 0.25; 95% CI, 0.19–0.33 [P<0.001] and 1‐year HR, 0.40; 95% CI, 0.33–0.48 [P<0.001] or no preoperative exposure/no current exposure (30‐day HR, 0.44; 95% CI, 0.32–0.60 [P<0.001] and 1‐year HR, 0.72; 95% CI, 0.62–0.84 [P<0.001] groups. The no preoperative exposure/current exposure group had significantly lower 30‐day (HR, 0.31; 95% CI, 0.14–0.71 [P=0.006]) and 1‐year (HR, 0.64; 95% CI, 0.53–0.77 [P<0.001]) mortality than the no preoperative exposure/no current exposure group. Conclusions Continuation of preoperative RASBs and initiation before discharge is associated with decreased mortality in veterans undergoing cardiac surgery. Given these findings, continuation of preoperative RASBs or initiation in the early postoperative period should be considered in patients undergoing cardiac surgery.
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Affiliation(s)
- Derrick T Antoniak
- Veterans Affairs Nebraska-Western Iowa Health Care System Omaha NE.,Division of General Internal Medicine Department of Medicine University of Nebraska Medical Center Omaha NE
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences Department of Medicine Creighton University Omaha NE
| | - Venkata M Alla
- Division of Cardiology Department of Medicine Creighton University Omaha NE
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Villanueva EW, Meissner H, Walters RW. Medical Student Perceptions of the Learning Environment, Quality of Life, and the School of Medicine's Response to the COVID-19 Pandemic: A Single Institution Perspective. Med Sci Educ 2021; 31:589-598. [PMID: 33585071 PMCID: PMC7864474 DOI: 10.1007/s40670-021-01223-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 05/09/2023]
Abstract
PURPOSE Responding to the COVID-19 pandemic, American medical schools made swift changes to clinical education based on guidelines provided by the Association of American Medical Colleges. The purpose of this study was to collect medical student perceptions of the solely online learning environment, their quality of life (QoL), and the pandemic response by their School of Medicine (SoM) to provide suggestions to inform medical schools' responses during the continuation of this pandemic and the next. METHODS Between April 29, 2020 and May 16, 2020, the authors distributed a 60-item questionnaire that assessed demographics, learning environment, QoL, and the SoM response. Likert-type items were analyzed on an item-by-item basis, whereas themes were identified for open-ended questions. RESULTS A total of 330 medical students (of 632; 52.2%) responded. Those who responded had positive perceptions of the online learning environment with moderate QoL disruptions to concentration and sleep. Although most students perceived being able to contribute meaningfully to the healthcare setting, they viewed themselves as underutilized. Three themes encapsulated both positive and negative perceptions of the SoM's response-communication, learning environment, and empathy and support. CONCLUSION These findings provide insight into medical student perceptions of their learning environment and QoL as they acclimated to changes resulting from the COVID-19 pandemic. Results can help inform a SoM's response during the continuation of the COVID-19 pandemic as well as during future pandemics or crises. Follow-up surveys of medical students at multiple institutions across the USA and abroad will be essential to better characterize student perceptions.
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Affiliation(s)
- Eric W. Villanueva
- Department of Medicine, University of Chicago (NorthShore), Evanston, IL USA
| | | | - Ryan W. Walters
- Division of Clinical Research and Evaluative Sciences, Department of Medicine, Creighton University, Omaha, NE USA
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Pajjuru VS, Thandra A, Guddeti RR, Walters RW, Jhand A, Andukuri VG, Alkhouli M, Spertus JA, Md VMA. Sex Differences in Mortality and 90-day Readmission Rates after Transcatheter aortic valve replacement (TAVR): A Nationwide Analysis from the United States. Eur Heart J Qual Care Clin Outcomes 2021; 8:135-142. [PMID: 33585884 DOI: 10.1093/ehjqcco/qcab012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/26/2021] [Accepted: 02/12/2021] [Indexed: 12/27/2022]
Abstract
AIM To assess gender differences in in-hospital mortality and 90-day readmission rates among patients undergoing Transcatheter aortic valve replacement (TAVR) in the United States. METHODS AND RESULTS Hospitalizations for TAVR were retrospectively identified in the National readmissions database (NRD) from 2012-2017. Gender based differences in in-hospital mortality and 90-day readmissions were explored using multivariable logistic regression models. During the study period, an estimated 171,361 hospitalizations for TAVR were identified, including 79,722 (46.5%) procedures in women and 91,639 (53.5%) in men. Unadjusted in-hospital mortality and 90-day all-cause readmissions were significantly higher for women compared to men (2.7% vs. 2.3%, p = .002; 25.1% vs. 24.1%; p = .012 respectively). After adjusting for baseline characteristics, women had 13% greater adjusted odds of in-hospital mortality (aOR: 1.13, 95% CI: 1.02-1.26, p = .017), and 9% greater adjusted odds of 90-day readmission compared to men (aOR: 1.09, 95% CI: 1.05-1.14, p < .001). During the study period, there was a steady decrease in hospital mortality (5.3% in 2012 to 1.6% in 2017; ptrend < .001) and 90-day (29.9% in 2012 to 21.7% in 2017; ptrend < .001) readmission rate in both genders. CONCLUSION In-hospital mortality and readmission rates for TAVR hospitalizations have decreased over time across both genders. Despite these improvements, women undergoing TAVR continue to have a modestly higher in-hospital mortality, and 90-day readmission rates compared to men. Given the expanding indications and use of TAVR, further research is necessary to identify the reasons for this persistent gap and design appropriate interventions.
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Affiliation(s)
- Venkata S Pajjuru
- Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Abhishek Thandra
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Raviteja R Guddeti
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Ryan W Walters
- Department of Medicine, Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE, USA
| | - Aravdeep Jhand
- Department of Medicine, Division of Cardiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Venkata G Andukuri
- Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Mohamad Alkhouli
- Department of Cardiology, Mayo Clinic, Rochester, Minnesota, USA
| | - John A Spertus
- Department of Medicine, Division of Cardiology, Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Venkata M Alla Md
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, NE, USA
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Jagan N, Morrow LE, Walters RW, Plambeck RW, Patel TM, Moore DR, Malesker MA. Sympathetic stimulation increases serum lactate concentrations in patients admitted with sepsis: implications for resuscitation strategies. Ann Intensive Care 2021; 11:24. [PMID: 33544243 PMCID: PMC7865043 DOI: 10.1186/s13613-021-00805-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/09/2021] [Indexed: 12/20/2022] Open
Abstract
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 < 65 mmHg) and was a significant predictor of mortality. Because HR, lactate, and MAP were associated with mortality, our data support the present strategy of using these measurements to gauge severity of illness upon presentation. Since HR did not moderate or mediate the association between lactate and death, criticisms alleging that lactate caused by sympathetic stimulation is adaptive (i.e., less harmful) do not appear substantiated.
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Affiliation(s)
- Nikhil Jagan
- Division of Pulmonary & Critical Care, Creighton University School of Medicine, 7710 Mercy Road, Suite 410, Omaha, NE, 68124, USA.
| | - Lee E Morrow
- Division of Pulmonary & Critical Care, Creighton University School of Medicine, 7710 Mercy Road, Suite 410, Omaha, NE, 68124, USA.,VA Nebraska-Western Iowa, Section of Pulmonary and Critical Care, Omaha, USA
| | - Ryan W Walters
- Division of Clinical Research & Evaluative Sciences, Creighton University School of Medicine, Omaha, USA
| | - Robert W Plambeck
- Division of Pulmonary & Critical Care, Creighton University School of Medicine, 7710 Mercy Road, Suite 410, Omaha, NE, 68124, USA
| | - Tej M Patel
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, USA
| | - Douglas R Moore
- Division of Pulmonary & Critical Care, Creighton University School of Medicine, 7710 Mercy Road, Suite 410, Omaha, NE, 68124, USA
| | - Mark A Malesker
- Creighton University School of Pharmacy and Health Professions, Omaha, USA
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Kousa O, Essa A, Saleh M, Ahsan MJ, Alali Y, Pajjuru V, Anani A, Ahmad A, Baskaran J, Walters RW, Sharma A, Haddad TM, Smer A. The Impact of Cardiology Consultation on Medical Intensive Care Unit Patients with Elevated Troponin Levels. Am J Med Sci 2020; 361:303-309. [PMID: 33268053 DOI: 10.1016/j.amjms.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/06/2020] [Accepted: 09/03/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSION Cardiology consultation for elevated cTn in medical ICU patients was associated with increased cardiac testing and LOS, without significant impact on mortality.
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Affiliation(s)
- Omar Kousa
- Department of Internal Medicine, Creighton University, Omaha, Nebraska
| | - Amr Essa
- Department of Internal Medicine, Creighton University, Omaha, Nebraska.
| | - Mohammed Saleh
- Department of Internal Medicine, Creighton University, Omaha, Nebraska
| | - Muhammad J Ahsan
- Department of Internal Medicine, Creighton University, Omaha, Nebraska
| | - Yaman Alali
- Department of Internal Medicine, Creighton University, Omaha, Nebraska
| | - Venkata Pajjuru
- Department of Internal Medicine, Creighton University, Omaha, Nebraska
| | | | - Aiza Ahmad
- Department of Internal Medicine, Creighton University, Omaha, Nebraska
| | - Janani Baskaran
- Department of Internal Medicine, Creighton University, Omaha, Nebraska
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, Creighton University, Omaha, Nebraska
| | - Arindam Sharma
- Division of Cardiology, Creighton University, Omaha, Nebraska
| | | | - Aiman Smer
- Division of Cardiology, Creighton University, Omaha, Nebraska
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Guddeti RR, Anwar M, Walters RW, Apala D, Pajjuru V, Kousa O, Gujjula NR, Alla VM. Treatment of Left Ventricular Thrombus With Direct Oral Anticoagulants: A Retrospective Observational Study. Am J Med 2020; 133:1488-1491. [PMID: 32598904 DOI: 10.1016/j.amjmed.2020.05.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/03/2020] [Accepted: 05/03/2020] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
| | | | - Ryan W Walters
- Divison of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, Neb
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Jagan N, Morrow LE, Walters RW, Plambeck RW, Patel TM, Kalian KF, Macaraeg JC, Dyer ED, Bergh AA, Fried AJ, Moore DR, Malesker MA. Sepsis, the Administration of IV Fluids, and Respiratory Failure: A Retrospective Analysis-SAIFR Study. Chest 2020; 159:1437-1444. [PMID: 33197405 DOI: 10.1016/j.chest.2020.10.078] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/18/2020] [Accepted: 10/21/2020] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Nikhil Jagan
- From the Division of Pulmonary & Critical Care, Omaha, NE.
| | - Lee E Morrow
- From the Division of Pulmonary & Critical Care, Omaha, NE
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, Omaha, NE
| | | | - Tej M Patel
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | | | | | - Emily D Dyer
- Creighton University School of Medicine, Omaha, NE
| | - Adam A Bergh
- Creighton University School of Medicine, Omaha, NE
| | - Aaron J Fried
- Department of Internal Medicine, University of North Carolina, Chapel Hill, NC
| | | | - Mark A Malesker
- From the Division of Pulmonary & Critical Care, Omaha, NE; Creighton University School of Pharmacy and Health Professions, Omaha, NE
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Pajjuru VS, Thandra A, Guddeti RR, Kothapalli SR, Walters RW, Jhand A, Aboeata A, Andukuri VG, Goldsweig AM. ST-elevation myocardial infarction in nonagenarians: A nationwide analysis of trends and outcomes in the United States. Catheter Cardiovasc Interv 2020; 98:638-646. [PMID: 33010099 DOI: 10.1002/ccd.29313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/03/2020] [Accepted: 09/21/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess ST elevation myocardial infarction (STEMI) trends and outcomes in nonagenarians undergoing primary percutaneous coronary intervention (pPCI) compared to medical management. BACKGROUND Although nonagenarians (age greater than 90 years) represent the fast-growing age decade of the US population, limited evidence is available regarding trends and outcomes of treatment strategies for STEMI in this population cohort. METHODS We performed a retrospective analysis using the National Inpatient Sample (NIS) database to identify nonagenarians presenting with STEMI and treated with either pPCI or medical management. In-hospital mortality, in-hospital complications, length of stay and in-hospital costs were analyzed. RESULTS Between 2010-2017, 41,042 STEMI hospitalizations were identified in nonagenarians, of which 11, 155 (27.2%) included pPCI whereas 29, 887 (72.8%) included medical management. STEMI hospitalizations among nonagenarians decreased over the study period. Overall unadjusted in-hospital mortality was 21.6%, and the hospitalizations that included pPCI had significantly lower mortality compared to the medical management (13.6% vs. 24.5%, p < .001). After adjusting for baseline characteristics, hospitalizations that included pPCI had 42.1% lower odds of in-hospital mortality (adjusted OR: 0.58, 95% CI: 0.50 to 0.67, p < .001). Altogether, in-hospital cardiac, bleeding and vascular complications, length of stay and in-hospital costs were higher in pPCI hospitalizations. CONCLUSION In nonagenarians, STEMI mortality is high, but pPCI is associated with superior outcomes compared to medical management alone. Therefore, pPCI can be considered an acceptable treatment strategy in this population.
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Affiliation(s)
- Venkata S Pajjuru
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Abhishek Thandra
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Raviteja R Guddeti
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | | | - Ryan W Walters
- Department of Medicine, Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, Nebraska
| | - Aravdeep Jhand
- Department of Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ahmed Aboeata
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Venkata G Andukuri
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Andrew M Goldsweig
- Department of Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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Jagan N, Morrow LE, Walters RW, Klein LP, Wallen TJ, Chung J, Plambeck RW. The POSITIONED Study: Prone Positioning in Nonventilated Coronavirus Disease 2019 Patients-A Retrospective Analysis. Crit Care Explor 2020; 2:e0229. [PMID: 33063033 PMCID: PMC7531752 DOI: 10.1097/cce.0000000000000229] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: Given perceived similarities between coronavirus disease 2019 pneumonia and the acute respiratory distress syndrome, we explored whether awake self-proning improved outcomes in coronavirus disease 2019-infected patients treated in a rural medical center with limited resources during a significant local coronavirus disease 2019 outbreak. Design: Retrospective analysis of prospectively collected clinical data. Setting: Single-center rural community-based medical center in Grand Island, NE. Patients: One hundred five nonintubated, coronavirus disease-infected patients. Interventions: None. Measurements and Main Results: After patients were educated on the benefits of awake self-proning, compliance was voluntary. The primary outcome was need for intubation during the hospital stay; secondary outcomes included serial peripheral capillary oxygen saturation measured by pulse oximetry to the Fio2 ratios, in-hospital mortality, and discharge disposition. Of 105 nonintubated, coronavirus disease-infected patients, 40 tolerated awake self-proning. Patients who were able to prone were younger and had lower disease severity. The risk of intubation was lower in proned patients after adjusting for disease severity using Sequential Organ Failure Assessment scores (adjusted hazard ratio, 0.30; 95% CI, 0.09–0.96; p = 0.043) or Acute Physiology and Chronic Health Evaluation II scores (adjusted hazard ratio, 0.30; 95% CI, 0.10–0.91; p = 0.034). No prone patient died compared with 24.6% of patients who were not prone (p < 0.001; number needed to treat = 5; 95% CI, 3–8). The probability of being discharged alive and peripheral capillary oxygen saturation measured by pulse oximetry to the Fio2 ratios were statistically similar for both groups. Conclusions: Awake self-proning was associated with lower mortality and intubation rates in coronavirus disease 2019-infected patients. Prone positioning appears to be a safe and inexpensive strategy to improve outcomes and spare limited resources. Prospective efforts are needed to better delineate the effect of awake proning on oxygenation and to improve patients’ ability to tolerate this intervention.
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Affiliation(s)
- Nikhil Jagan
- Division of Pulmonary and Critical Care, Creighton University School of Medicine, Omaha, NE
| | - Lee E Morrow
- Division of Pulmonary and Critical Care, Creighton University School of Medicine, Omaha, NE.,Division of Pulmonary and Critical Care, Nebraska-Western Iowa VA Medical Center, Omaha, NE
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE
| | - Lauren P Klein
- Division of Pulmonary and Critical Care, CHI Health, Omaha, NE
| | - Tanner J Wallen
- Division of Pulmonary and Critical Care, Saint Louis University School of Medicine, St. Louis, MO
| | - Jacqueline Chung
- Division of Pulmonary and Critical Care, Creighton University School of Medicine, Omaha, NE
| | - Robert W Plambeck
- Division of Pulmonary and Critical Care, Creighton University School of Medicine, Omaha, NE
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