Faculty Bibliography

INTRODUCTION: Propofol has been widely used in the ICU for sedation and refractory status epilepticus. PRIS is a serious and potentially fatal condition that is characterized by a spectrum of clinical symptoms and abnormalities. Literature suggests that a longer duration of propofol >= 48 hours or a dose >= 83 mcg/kg/min is associated with a higher risk of PRIS. Many of the critically ill patients in our health system required a larger dose of propofol and prolonged duration of infusion for sedation in the ICU, especially during Covid-19. Delayed treatment of PRIS can lead to death. It is very likely that patients who develop PRIS may often go unrecognized as the manifestations of PRIS can overlap with common ICU conditions. The current prevalence of PRIS is unknown, however, a prospective study has reported a prevalence of 1.1% in critically ill patients.
METHOD(S): Patients were identified by querying the NYU Langone Health COVID clinical data mart from March 2020 till February 2021. The inclusion criteria included patients receiving propofol infusion for >= 48 hours or receiving a dose >= 60 mcg/kg/min for more than 24 hours. Pregnant patients, children, and patients with rhabdomyolysis prior to the start of infusion were excluded. PRIS was defined by the development of metabolic acidosis and cardiac dysfunction with 2 or more minor criteria (rhabdomyolysis, hypertriglyceridemia, renal failure, and hepatic transaminitis) or developing 3 or more minor criteria.
RESULT(S): 424 patients were included in our study. Of the 424 patients, 21 patients were found to have developed PRIS. The occurrence of PRIS was observed at the median infusion rate of 36.1 mcg/kg/min and a median duration of infusion of 147 hours. The prevalence of PRIS was found to be 4.9%.
CONCLUSION(S): The prevalence of PRIS in our study was found to be 4.9%. The occurrence of PRIS was observed at the median infusion rate of 36.1 mcg/kg/min suggesting that PRIS can be developed at a lower rate of infusion than previously reported. We suggest that patients - especially those receiving a duration >= 48 hours and a higher dose of 60 mcg/kg/min - should be monitored for signs and symptoms of PRIS during propofol infusion as it may be underrecognized because PRIS is characterized by multiple clinical manifestations that overlap with critical illness

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

Background: Tremendous therapeutic progress has been made over the past decade in the field of multiple myeloma (MM). Although the incidence of MM is twice as high for black compared to white individuals, mortality rates remain higher for black patients (Marinac, et al. Blood Ca J 2020). In addition, black Americans are significantly less likely to participate in clinical trials in general (Hong, et al. Am J Prev Med 2021), leading to disproportionate enrollment in studies of novel agents. Various factors may account for these disparities, including access to clinical trials, clinician bias, and hesitancy to enroll in clinical trials among different patient populations. Furthermore, underrepresentation of racial groups within clinical trials impacts the generalizability of important findings from these studies. Here we characterized the racial representation of MM clinical trials.
Method(s): Randomized clinical trials focused on MM interventions published between 2012-2022 were included. We screened 431 publications during this period and characterized racial demographics as available in the literature. A twosided Cochran-Armitage Trend Test was used to assess if there was a linear trend in the percentage of black participants in clinical trials over time.
Result(s): Among 431 studies published over the past 10 years, 76 collected over past 5 years that included racial demographic details were included. Among the 38,830 participants, 87.5% were white, 4.8% were black, and 7.7% were other (reported as either Asian, mixed, or other). There was a significant trend toward increased enrollment comparing over time between 2018 to 2021 (2.1 to 7.0%, p < 0.001 for trend), however black individual remained largely underrepresented in all these studies.
Conclusion(s): While the number of black participating in randomized controlled trials involving MM patients over the past five years is significantly increasing, these studies included a disproportionate number of white participants, despite the incidence of MM being higher for black patients. Efforts are underway in the field to enhance enrollment of underrepresented populations, including a recent randomized study that included 19% black MM patients (Richardson, et al. New Eng J Med 2022). Our study was limited due to many trials not reporting details about racial demographics until relatively recently. Further investigations required to examine the reasons underlying racial disparities in MM trial recruitment and enrollment

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.

PURPOSE/OBJECTIVE:Safety of remdesivir in patients with renal impairment is unknown. Incidence of liver injury secondary to remdesivir is also unknown. The objective of this study is to assess the incidence of acute kidney injury (AKI) and to trend the liver enzymes during remdesivir treatment and change in eGFR from baseline to end of treatment as well as 48 h post completion of remdesivir therapy. METHODS:This is a retrospective chart review study including adult patients admitted with COVID-19 receiving remdesivir with a baseline eGFR < 30 ml/min per 1.73 m^2 from December 2020 to May 2021. The primary outcome was to assess the incidence of AKI and hepatic injury. The secondary outcome was to assess the efficacy of remdesivir defined by change in oxygen requirement. RESULTS:Seventy-one patients were included in the study. Patients experienced an improvement in eGFR from baseline (T0) to end of remdesivir treatment (T1), as well as 48 h after the end of the treatment (T2) ( + 30.3% and + 30.6% respectively, P < .0001). Creatinine reduced from baseline (T0) to T1 and T2 (-20.9% and -20.5% respectively, P < .0001). Creatinine clearance improved from baseline to T1 and T2 ( + 26.6% and + 26.2% respectively, p < .0001). Elevation of aminotransferase (AST) was observed at T1 ( + 2.5%, P  =  .727), however, AST reduction was seen at T2 (-15.8%, P  =  .021). Elevation in alanine transaminase (ALT) was observed at T1 and T2 ( + 25% and + 12%, P  =  .004 and P  =  .137 respectively). Both direct and total bilirubin remained stable and were not significantly changed from baseline. CONCLUSION/CONCLUSIONS:Our study showed that remdesivir use in renally-impaired patients with eGFR < 30 ml/min is safe. Remdesivir may be considered as a therapeutic option in this population with COVID-19 infection.

BACKGROUND:The physician work Relative Value Unit (wRVU) scale is the primary determinant of compensation. Operative time, technical skill, effort, and surgical complexity contribute to wRVU allocation. The aim of this study is to identify the relationship between these factors and reimbursement for trauma procedures. METHODS:The National Surgical Quality Improvement Program (NSQIP) database was queried for orthopedic trauma procedures from 2016-18. Physician wRVU data was obtained from the 2020 Centers for Medicare & Medicaid Services fee schedule. The primary outcome measured was mean wRVU per minute of operative time (wRVU/min). Wilcoxon rank-sum test and quantile regression were used to determine the association between wRVU, operative time, complication rate, upper or lower extremity procedure, and wRVU/min. RESULTS:63 CPT codes or 107,171 cases queried. Median wRVU/min was significantly lower for longest 50% of procedures (0.119vs0.160, p<0.001) and higher for the top 50% with regard to complication rate (0.161vs0.124, p<0.001). Upper extremity procedures were reimbursed less than lower extremity (0.110vs0.145, p<0.001). Quintile regression showed that adjusted for complication rate, median wRVU/min decreased by 0.0005 (95% CI: 0.0007-0.0003, R1=0.27, p<0.001) for every additional minute of operative time. CONCLUSIONS:The 2020 wRVU scale does not allocate sufficient wRVUs to orthopedic trauma procedures with longer mean operative time or to procedures performed on the upper extremity. There is a negative correlation between operative time and hourly reimbursement, equating to a decrease of $64.96/hour per hour of operation. LEVEL OF EVIDENCE/METHODS:Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:) level and poor outcomes in hospitalized patients with diabetes and COVID-19. METHODS:results for each patient were divided into quartiles; 5.1-6.7% (32-50 mmol/mol), 6.8-7.5% (51-58 mmol/mol), 7.6-8.9% (60-74 mmol/mol), and >9% (>75 mmol/mol). The primary outcome was in-hospital mortality. Secondary outcomes included admission to an intensive care unit, invasive mechanical ventilation, acute kidney injury, acute thrombosis, and length of hospital stay. RESULTS:Five hundred and six patients were included. The number of deaths within quartiles 1 through 4 were 30 (25%), 37 (27%), 34 (27%) and 24 (19%), respectively. There was no statistical difference in the primary or secondary outcomes between the quartiles except acute kidney injury was less frequent in quartile 4. CONCLUSIONS:should not be used for risk stratification in these patients.

Thyroid function tests (TFTs) are routinely checked in hospitalized patients with or without pre-existing thyroid disease, sometimes even without suspicion of thyroid derangement. Although alternative diagnoses may explain presentations, cultural norms often encourage routine assessment. The objective of this study was to evaluate whether routine measurement of TFTs is beneficial, unnecessary, or even harmful in cost-effective care for hospitalized patients. This is a retrospective observational study of 2278 patients admitted to an academic hospital over a 5.5-month period who had their TFTs checked. Chart notes were reviewed to evaluate for preadmission diagnosis of thyroid disease and clinical indications for ordering TFTs. Results of thyroid function testing were reviewed. Medical records of those with abnormal TFTs were reviewed to assess whether thyroid medication was initiated or adjusted. Of the thyroid function tests ordered, 20.1% were ordered due to suspicion of thyroid dysfunction, 20.8% due to history of thyroid disease, and 59.0% for reasons not directly related to thyroid dysfunction. 27.3% of those tested had abnormal results. The percentage of abnormal TFTs that led to medication initiation or adjustment was 15.1%, 12.1%, and 5.7%, for those tested on the basis of history of thyroid disease, suspicion of thyroid dysfunction, and reasons not directly related to thyroid dysfunction, respectively. Overall, 65 patients were started on thyroid medication or had the dosage of their thyroid medication adjusted, which represents 10.4% of those with abnormal TFTs and only 2.9% of those tested. Abnormal thyroid function test results 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. TFTs checked for reasons not directly related to thyroid dysfunction had the lowest percentage of results that led to medication initiation or adjustment, while those checked on the basis of history of thyroid disease had the highest. 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

BACKGROUND:Severe hypoxic respiratory failure from COVID-19 pneumonia carries a high mortality risk. There is uncertainty surrounding which patients benefit from corticosteroids in combination with tocilizumab and the dosage and timing of these agents. The balance of controlling inflammation without increasing the risk of secondary infection is difficult. At present, dexamethasone 6 mg is the standard of care in COVID-19 hypoxia; whether this is the ideal choice of steroid or dosage remains to be proven. OBJECTIVES/OBJECTIVE:The primary objective was to assess the impact on mortality of tocilizumab only, corticosteroids only, and combination therapy in patients with COVID-19 respiratory failure. METHODS:A multihospital, retrospective study of adult patients with severe respiratory failure from COVID-19 who received supportive therapy, corticosteroids, tocilizumab, or combination therapy were assessed for 28-day mortality, biomarker improvement, and relative risk of infection. Propensity-matched analysis was performed between corticosteroid alone and combination therapies to further assess mortality benefit. RESULTS:= 0.005] without increasing the risk of infection. CONCLUSION AND RELEVANCE/UNASSIGNED:Combination of tocilizumab and corticosteroids was associated with improved 28-day survival when compared with corticosteroids alone. Modification of steroid dosing strategy as well as steroid type may further optimize therapeutic effect of the COVID-19 treatment.

Respiratory viral infections (RVIs) affect children year-round, with seasonal-specific patterns. Pediatric oncology patients are uniquely vulnerable to infection, but whether this predisposes them to different patterns of RVIs than healthy children is unknown. There is also limited data on the impact of RVIs on cancer patients. We conducted a retrospective study of children ages 1-21 with cancer presenting to the clinic and emergency department (ED) and a randomly selected subset of patients without cancer presenting to the ED who had positive nasopharyngeal viral polymerase chain reactions at our institution from 2014 to 2019. Sixty-seven cancer patients (206 RVI episodes) and 225 pediatric non-cancer patients (237 RVI episodes) were included. Human rhino/enterovirus (HRE) was the most common infection in both groups in the spring, summer, and fall. In the winter, the most common RVI was influenza in cancer patients verses respiratory syncytial virus in non-cancer patients. On age-adjusted analysis, the likelihood of detecting coronavirus in the winter, HRE in the spring and fall, and parainfluenza in the summer was significantly greater in cancer patients (OR = 2.60, 2.52, 5.73, 3.59 respectively). Among cancer RVI episodes, 50% received parenteral antibiotics, 22% were severely neutropenic, 22% had chemotherapy delays for a median of six days, 16% were hospitalized, and 6% received intravenous immunoglobulin. We conclude that there are differences in the seasonal patterns of RVIs between children with and without cancer. RVIs also cause significant morbidity in children with cancer.