Faculty Bibliography

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:African American (AA) recipients of deceased-donor (DD) kidney transplants (KT) have shorter allograft survival than recipients of other ethnic groups. Reasons for this disparity encompass complex interactions between donors and recipients characteristics. METHODS:Outcomes from 3872 AA and 19,719 European American (EA) DDs who had one kidney transplanted in an AA recipient and one in an EA recipient were analyzed. Four donor/recipient pair groups (DRP) were studied, AA/AA, AA/EA, EA/AA, and EA/EA. Survival random forests and Cox proportional hazard models were fitted to rank and evaluate modifying effects of DRP on variables associated with allograft survival. These analyses sought to identify factors contributing to the observed disparities in transplant outcomes among AA and EA DDKT recipients. RESULTS:Transplant era, discharge serum creatinine, delayed graft function, and DRP were among the top predictors of allograft survival and mortality among DDKT recipients. Interaction effects between DRP with the kidney donor risk index and transplant era showed significant improvement in allograft survival over time in EA recipients. However, AA recipients appeared to have similar or poorer outcomes for DDKT performed after 2010 versus before 2001; allograft survival hazard ratios (95% CI) were 1.15 (0.74, 1.76) and 1.07 (0.8, 1.45) for AA/AA and EA/AA, compared to 0.62 (0.54, 0.71) and 0.5 (0.41, 0.62) for EA/EA and AA/EA DRP, respectively. Recipient mortality improved over time among all DRP, except unemployed AA/AAs. Relative to DDKT performed pre-2001, employed AA/AAs had HR = 0.37 (0.2, 0.69) versus 0.59 (0.31, 1.11) for unemployed AA/AA after 2010. CONCLUSION/CONCLUSIONS:Relative to DDKT performed before 2001, similar or worse overall DCAS was observed among AA/AAs, while EA/EAs experienced considerable improvement regardless of employment status, KDRI, and EPTS. AA recipients of an AA DDKT, especially if unemployed, had worse allograft survival and mortality and did not appear to benefit from advances in care over the past 20 years.

BACKGROUND:Data access through smartphone applications (apps) has reframed procedure and policy in healthcare, but its impact in trauma remains unclear. Citizen is a free app that provides real-time alerts curated from 911 dispatch data. Our primary objective was to determine whether app alerts occurred earlier than recorded times for trauma team activation and emergency department arrival. METHODS:Trauma registry entries were extracted from a level one urban trauma center from January 1, 2018 to June 30, 2019 and compared with app metadata from the center catchment area. We matched entries to metadata according to description, date, time, and location then compared metadata timestamps to trauma team activation and emergency department arrival times. We computed percentage of time the app reported traumatic events earlier than trauma team activation or emergency department arrival along with exact binomial 95% confidence interval; median differences between times were presented along with interquartile ranges. RESULTS:Of 3,684 trauma registry entries, 209 (5.7%) matched app metadata. App alerts were earlier for 96.1% and 96.2% of trauma team activation and emergency department arrival times, respectively, with events reported median 36 (24-53, IQR) minutes earlier than trauma team activation and 32 (25-42, IQR) minutes earlier than emergency department arrival. Registry entries for younger males, motor vehicle-related injuries and penetrating traumas were more likely to match alerts (P < .0001). CONCLUSION/CONCLUSIONS:Apps like Citizen may provide earlier notification of traumatic events and therefore earlier mobilization of trauma service resources. Earlier notification may translate into improved patient outcomes. Additional studies into the benefit of apps for trauma care are warranted.

Background/UNASSIGNED:Patients on maintenance hemodialysis are particularly vulnerable to infection and hospitalization from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Due to immunocompromised patients and the clustering that occurs in outpatient dialysis units, the seroprevalence of COVID-19 antibodies in this population is unknown and has significant implications for public health. Also, little is known about their risk factors for hospitalization. Methods/UNASSIGNED:nasopharyngeal, real-time, reverse-transcriptase PCR (RT-PCR); SARS-CoV-2 IgG seropositivity; hospitalization; and mortality. Results/UNASSIGNED:<0.001) compared with those who tested negative. Higher positivity rates were also observed among those who took taxis and ambulettes to and from dialysis, compared with those who used personal transportation. Antibodies were detected in all of the patients with a positive PCR result who underwent serologic testing. Of those that were seropositive, 32% were asymptomatic. The hospitalization rate on the basis of either antibody or PCR positivity was 35%, with a hospital mortality rate of 33%. Aside from COPD, no other variables were more prevalent in patients who were hospitalized. Conclusions/UNASSIGNED:We observed significant differences in rates of COVID-19 infection within three outpatient dialysis units, with universal seroconversion. Among patients with ESKD, rates of asymptomatic infection appear to be high, as do hospitalization and mortality rates.

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

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.

BACKGROUND/UNASSIGNED:Continuous subcutaneous insulin infusion (CSII) is a common diabetes treatment modality. Glycemic outcomes of patients using CSII in the first 24 hours of hospitalization have not been well studied. This timeframe is of particular importance because insulin pump settings are programmed to achieve tight outpatient glycemic targets which could result in hypoglycemia when patients are hospitalized. METHODS/UNASSIGNED:This retrospective cohort study evaluated 216 hospitalized adult patients using CSII and 216 age-matched controls treated with multiple daily injections (MDI) of insulin. Patients using CSII did not make changes to pump settings in the first 24 hours of admission. Blood glucose (BG) values within the first 24 hours of admission were collected. The primary outcome was frequency of hypoglycemia (BG < 70 mg/dL). Secondary outcomes were frequency of severe hypoglycemia (BG < 40 mg/dL) and hyperglycemia (BG ≥ 180 mg/dL). RESULTS/UNASSIGNED: = 0.06). CONCLUSIONS/UNASSIGNED:Patients using CSII experienced fewer events of both hypoglycemia and hyperglycemia in the first 24 hours of hospital admission than those treated with MDI. Our study demonstrates that CSII use is safe and effective for the treatment of diabetes within the first 24 hours of hospital admission.