Faculty Bibliography

There has been a recent increase in the incidence of urinary tract infections (UTIs) caused by extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae, which are resistant to third-generation cephalosporins. Our goal was to compare the clinical responses of patients with ESBL UTI and non-ESBL UTI who received empiric third-generation cephalosporins. A retrospective analysis was performed on data collected between June 1, 2013, and June 30, 2017, from children aged 0 days to 19 years old who presented to NYU Langone Long Island Hospital's pediatric ED and/or were admitted with a UTI caused by Enterobacteriaceae. There was no significant difference in median length of fever duration. However, ESBL patients had significantly longer hospital stays, higher 30-day readmission rate, and higher 7-day revisit rate. It is reasonable to maintain an empiric UTI antibiotic choice rather than selecting a broad-spectrum antibiotic, such as carbapenem for children at high risk of ESBL UTI.

Background Peripheral artery disease (PAD) affects >10 million people in the United States. PAD is associated with poor outcomes, including premature death. Machine learning (ML) has been increasingly used on big data to predict clinical outcomes. This study aims to develop ML models to predict in-hospital mortality in patients hospitalized for PAD based on a national database. Methods and Results Inpatient hospitalization data were obtained from the 2016 to 2019 National Inpatient Sample. A total of 150 921 inpatients were identified with a primary diagnosis of PAD and PAD-related procedures using codes of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). Four ML models, including logistic regression, random forest, light gradient boosting, and extreme gradient boosting models, were trained to predict the risk of in-hospital death based on a selection of variables, including patient characteristics, comorbidities, procedures, and hospital-related factors. In-hospital mortality occurred in 1.8% of patients. The performance of the 4 models was comparable, with the area under the receiver operating characteristic curve ranging from 0.83 to 0.85, sensitivity of 77% to 82%, and specificity of 72% to 75%. These results suggest adequate predictability for clinical decision-making. In all 4 models, the total number of diagnoses and procedures, age, endovascular revascularization procedure, congestive heart failure, diabetes, and diabetes with complications were critical predictors of in-hospital mortality. Conclusions This study demonstrates the feasibility of ML in predicting in-hospital mortality in patients with a primary PAD diagnosis. Findings highlight the potential of ML models in identifying high-risk patients for poor outcomes and guiding personalized intervention.

INTRODUCTION/BACKGROUND:Coronavirus disease 2019 (COVID-19) has been shown to affect outcomes among surgical patients. We hypothesized that COVID-19 would be linked to higher mortality and longer length of stay of trauma patients regardless of the injury severity score (ISS). METHODS:We performed a retrospective analysis of trauma registries from two level 1 trauma centers (suburban and urban) from March 1, 2019, to June 30, 2019, and March 1, 2020, to June 30, 2020, comparing baseline characteristics and cumulative adverse events. Data collected included ISS, demographics, and comorbidities. The primary outcome was time from hospitalization to in-hospital death. Outcomes during the height of the first New York COVID-19 wave were also compared with the same time frame in the prior year. Kaplan-Meier method with log-rank test and Cox proportional hazard models were used to compare outcomes. RESULTS:There were 1180 trauma patients admitted during the study period from March 2020 to June 2020. Of these, 596 were never tested for COVID-19 and were excluded from the analysis. A total of 148 COVID+ patients and 436 COVID- patients composed the 2020 cohort for analysis. Compared with the 2019 cohort, the 2020 cohort was older with more associated comorbidities, more adverse events, but lower ISS. Higher rates of historical hypertension, diabetes, neurologic events, and coagulopathy were found among COVID+ patients compared with COVID- patients. D-dimer and ferritin were unreliable indicators of COVID-19 severity; however, C-reactive protein levels were higher in COVID+ relative to COVID- patients. Patients who were COVID+ had a lower median ISS compared with COVID- patients, and COVID+ patients had higher rates of mortality and longer length of stay. CONCLUSIONS:COVID+ trauma patients admitted to our two level 1 trauma centers had increased morbidity and mortality compared with admitted COVID- trauma patients despite age and lower ISS. C-reactive protein may play a role in monitoring COVID-19 activity in trauma patients. A better understanding of the physiological impact of COVID-19 on injured patients warrants further investigation.

BACKGROUND:Previous studies have reported low value of ordering inpatient thyroid function tests (TFTs), with few changes in clinical management resulting from these tests. This study was designed to evaluate how often testing TFTs during hospitalization leads to medication initiation or adjustment, and to determine if the frequency of medication initiation or adjustment differs based on the indication for testing. METHODS:This is a retrospective observational study of 2278 patients who had TFTs tested while admitted to an academic hospital during a 5-month period. Indications for ordering TFTs were determined by reviewing clinical documentation, and those with abnormal tests were reviewed to assess whether thyroid medication was initiated or adjusted. RESULTS:The percentage of abnormal TFTs that led to medication initiation or adjustment was 15.1%, 12.2%, and 6.0%, for those tested on the basis of history of functional thyroid disease, suspicion of thyroid dysfunction, and reasons not directly related to thyroid dysfunction, respectively. Overall, 63 patients were started on thyroid medication or had their thyroid medication dose adjusted, which represents 10.1% of those with abnormal TFTs and only 2.8% of those tested. CONCLUSION/CONCLUSIONS:Abnormal TFTs are common, but a disproportionate amount of tests are needed to find a small percentage of clinically significant thyroid dysfunction, of which only a low percentage lead to changes in management. Education on this topic should be provided to inpatient providers to limit thyroid function testing to instances in which they are clinically indicated and abnormal results would lead to changes in management.

PURPOSE/OBJECTIVE:PRIS is a potentially fatal syndrome characterized by various clinical symptoms and abnormalities. Experts suggest that propofol treatment duration ≥48 h or dose ≥83 μg/kg/min is associated with developing PRIS. We hypothesized PRIS might be underdiagnosed due to the overlap of PRIS clinical manifestations with critical illnesses. MATERIALS AND METHODS/METHODS:Multihospital, retrospective study of adult patients who received continuous propofol infusion ≥48 h or dose ≥60μg/kg/min for >24 h since admission were assessed for the development of PRIS. RESULTS:The incidence of PRIS was 2.9% with a PRIS-associated mortality rate of 36.8%. In PRIS patients, propofol was administered at a median dose of 36.4 μg/kg/min and over a median duration of 147.0 h. The development of PRIS was observed at a median of 125.0 h post-propofol initiation and a cumulative dose of 276.5 mg/kg. The development of metabolic acidosis (78.9%), cardiac dysfunction (52.6%), hypertriglyceridemia (100%), and rhabdomyolysis (26.3%) were observed in our PRIS patients. CONCLUSION/CONCLUSIONS:PRIS can often be overlooked and underdiagnosed. It is important to monitor for early signs of PRIS in patients who are on prolonged propofol infusion. Prompt recognition and interventions can minimize the dangers resulting from PRIS.

PURPOSE:Palliative care (PC) plays an established role in improving outcomes in patients with solid tumors, yet these services are underutilized in hematologic malignancies (HMs). We reviewed records of hospitalized patients with active HM to determine associations between PC consultation and length of stay, intensive care unit stay, 30-day readmission, and 6-month mortality compared with those who were not seen by PC. METHODS:We reviewed all oncology admissions at our institution between 2013 and 2019 and included patients with HM actively on treatment, stratified by those seen by PC to controls not seen by PC. Groups were compared using Wilcoxon rank-sum, chi-square, and Fisher's exact tests on the basis of the type and distribution of data. Multiple logistic regression models with stepwise variable selection methods were used to find predictors of outcomes. RESULTS:< .001). These data were confirmed in multivariable models. CONCLUSION:In this retrospective study, more than two thirds of patients with HM did not receive PC consultation despite having similar comorbidities, suggesting that inpatient PC consultation is underutilized in patients with HM, despite the potential for decreased readmission rates.

Background and Objectives/UNASSIGNED:Despite the growth of minimally invasive surgery (MIS) in many specialties, open colon surgery is still routinely performed. The purpose of this study was to compare outcomes and costs between open colon and minimally invasive colon resections. Methods/UNASSIGNED:test was used for categorical variables. Multiple Logistic and Quintile regression were used for multivariable analyses. Results/UNASSIGNED:A total of 88,405 elective colon resections (open: 56,599; minimally invasive: 31,806) were reviewed. A significantly larger proportion of patients undergoing minimally invasive surgery were obese (body mass index > 30) compared to those undergoing open surgery (71.4% vs. 59.6%; p < 0.0001). As compared to minimally invasive colectomy, open colectomy patients had: a longer median length of stay [median (range): 7 (4-13) days vs. 4 (3 - 6) days, p < 0.0001], higher 30-day readmission rate [n = 8557 (15.1%) vs. 2815 (8.9%), p < 0.0001], higher mortality [n = 2590 (4.4%) vs. 107 (0.34%), p < 0.0001], and a higher total direct cost [median (range): $13,582 (9041-23,094) vs. $9013 (6748 - 12,649), p < 0.0001]. Multivariable models confirmed these findings. Conclusion/UNASSIGNED:Minimally invasive colon surgery has clear benefits in terms of length of stay, readmission rate, mortality and cost, and the routine use of open colon resection should be revaluated.

As the population ages, more older adults will undergo surgical procedures, and common physiologic changes can raise the risk for surgical complications while increasing morbidity and mortality. In conjunction with the National Surgical Quality Improvement Program, we piloted a comprehensive and interdisciplinary assessment and intervention protocol for perioperative care for patients aged ≥75 years undergoing elective general, gynecology-oncologic, and orthopedic surgery. The intervention included screening tools for cognitive, functional, and nutritional deficits, a Geriatric Nurse Champion on each inpatient surgical unit, and an interdisciplinary Geriatric Surgery Quality Committee. Our intervention group was compared to surgical patients during the same time period 1 year prior to the intervention, and the groups were well matched in demographics and comorbidities. The intervention group had significantly higher rates of advance care plan documentation in analysis of all patients (P < .001) and in subgroup analysis of those 85 and older (P = .006). The preintervention group had less postoperative delirium compared to the postintervention group but it was not significant and there was no difference in length of stay between groups. Various explanations for the minimal impact of the protocol exist: small sample size, presence of other hospital initiatives to reduce pressure ulcer and delirium, and clinician's awareness of project planning that led to incorporating ideas prior to official implementation. Future research implementing this protocol in naïve and/or underperforming institutions may demonstrate a greater effect. Larger sample size as well as implementation in other surgical fields may reveal a significant impact. However, if additional study does not reveal a meaningful impact of a comprehensive geriatric assessment for surgical patients, then consideration must be made regarding unrecognized factors in surgical care for older adults or perhaps that factors cannot be mitigated in older adults because they are intrinsically a higher surgical risk.

PURPOSE: Conclusive data on safety of remdesivir in renal impaired as well as the incidence of liver injury are lacking. The primary objective of this study is to assess the incidence of acute kidney injury (AKI) and to trend the liver function tests (LFTs) during remdesivir treatment and change in eGFR from baseline to end of remdesivir treatment as well as 48 hours after completion of therapy.
METHOD(S): This is a retrospective chart review study including adult Covid19 patients receiving remdesivir with a baseline eGFR< 30 ml/min per 1.73 m^2 from December 2020 to May 2021. The primary outcome of the study is the incidence of AKI and hepatic injury. The secondary outcome is to assess the efficacy of remdesivir defined by oxygen requirement during therapy.
RESULT(S): Seventy-one patients were included in the study. Average eGFR improved by 30.3% at the immediate end of remdesivir treatment and by 30.6% at 48 hours after the end of the treatment (both P< 0.0001). Comparing to baseline, creatinine at the end of remdesivir treatment decreased by 20.9% (P< 0.0001), creatinine of 48 hour after remdesivir treatment decreased by 20.5% (P< 0.0001). Creatinine clearance increased by 26.6% (P< 0.0001) at end of treatment and increased by 26.2% (P< 0.0001) by 48 hours after end of treatment. AST average increased by 2.5% at the end of remdesivir treatment (P=0.727). At 48 hours after remdesivir completion, average AST dropped by 15.8% (P=0.021). ALT average increased by 25% (P=0.004) at the end of remdesivir treatment and increased by 12.0% (P=0.137) at 48 hours after remdesivir completion. Both direct and total bilirubin at end of remdesivir treatment as well as 48 hours later remained stable and did not have significant changes from baseline (P >0.05). Overall, 38% (27 out of 71 patients) experienced oxygenation improvement shown by down-titration of oxygen therapy. Fifty-seven percent of patients received other nephrotoxic medications. The mortality rate is 33.8%. Fifteen of the 71 patients were admitted into ICU. Sixty-five percent (46/71) patients were discharged alive from hospital.
CONCLUSION(S): This study showed that remdesivir use in renally impaired Covid 19 patients with eGFR< 30 ml/min is safe and effective. However, large and prospective studies are needed to validate our findings