Faculty Bibliography

PURPOSE OF REVIEW/OBJECTIVE:The use of POCUS has grown tremendously with the introduction of innovative, easy-to-carry and maneuver hand-held devices. This review focuses on nephrology-centric applications of POCUS that can be incorporated on a daily basis to make impactful and prompt clinical decisions. RECENT FINDINGS/RESULTS:We review articles covering use of POCUS in the dialysis unit, the Emergency Department, office, and ICU for assessment of volume status, access issues, stones, obstruction, and to help manage patients with AKI, shock, and heart failure. SUMMARY/CONCLUSIONS:POCUS is a welcome addition to our bedside diagnostic armamentarium and has great utility in nephrology. Trials are ongoing in evaluating outcomes with POCUS and physicians' clinical experience using it has been extremely positive.

Patients with kidney failure and acute respiratory distress syndrome (ARDS) requiring prone position have not been candidates for peritoneal dialysis (PD) due to concern with increased intra-abdominal pressure, reduction in respiratory system compliance and risks of peritoneal fluid leaks. We describe our experience in delivering acute PD during the surge in Covid-19 acute kidney injury (AKI) in the subset of patients requiring prone positioning. All seven patients included in this report were admitted to the intensive care unit with SARS-CoV-2 infection leading to ARDS, AKI and multisystem organ failure. All required renal replacement therapy, and prone positioning to improve ventilation/perfusion mismatch. All seven were able to continue PD despite prone positioning without any detrimental effects on respiratory mechanics or the need to switch to a different modality. Fluid leakage was noted in 71% of patients, but mild and readily resolved. We were able to successfully implement acute PD in ventilator-dependent prone patients suffering from Covid-19-related AKI. This required a team effort and some modifications in the conventional PD prescription and delivery.

BACKGROUND:Evidence-based preventive care in the USA is underutilized, diminishing population health and worsening health disparities. We developed Project ACTIVE, a program to improve adherence with preventive care goals through personalized and patient-centered care. OBJECTIVE:To determine whether Project ACTIVE improved utilization of preventive care and/or estimated life expectancy compared to usual care. DESIGN/METHODS:Single-site randomized controlled trial. PARTICIPANTS/METHODS:Cluster-randomized 140 English or Spanish speaking adult patients in primary care with at least one of twelve unfulfilled preventive care goals based on USPSTF grade A and B recommendations. INTERVENTION/METHODS:Project ACTIVE employs a validated mathematical model to predict and rank individualized estimates of health benefit that would arise from improved adherence to different preventive care guidelines. Clinical staff engaged the participant in a shared medical decision-making (SMD) process to identify highest priority unfulfilled clinical goals, and health coaching staff engaged the participant to develop and monitor action steps to reach those goals. MAIN MEASURES/METHODS:Change in number of unfulfilled preventive care goals from USPSTF grade A and B recommendations and change in overall gain in estimated life expectancy. KEY RESULTS/RESULTS:In an intent-to-treat analysis, Project ACTIVE increased the average number of fulfilled preventive care goals out of 12 by 0.68 in the intervention arm compared with 0.15 in the control arm (mean difference [95% CI] 0.53 [0.19-0.86]), yielding a gain in estimated life expectancy of 8.8 months (3.8, 14.2). In a per-protocol analysis, Project ACTIVE increased fulfilled preventive care goals by 0.80 in the intervention arm compared with 0.16 in the control arm (mean difference [95% CI], 0.65 [0.25-1.04]), yielding a gain in estimated life expectancy of 13.7 months (6.2, 21.2). Among the 12 preventive care goals, more improvement occurred for alcohol use, hypertension, hyperlipidemia, depression, and smoking. CONCLUSIONS:Project ACTIVE improved unfulfilled preventive care goals and improved estimated life expectancy. CLINICAL TRIAL REGISTRATION NUMBER/BACKGROUND:NCT04211883.

BACKGROUND:Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health, and mental health of patients 1 month after discharge for severe COVID-19. METHODS:This was a prospective single health system observational cohort study of patients ≥ 18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 l of oxygen during admission, had intact baseline cognitive and functional status, and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS® Dyspnea Characteristics and PROMIS® Global Health-10. RESULTS:A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p < 0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p < 0.001. Physical and mental health means in the general US population are 50 (SD 10). A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey. CONCLUSIONS:Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health, and mental health for at least several weeks after hospital discharge.

PURPOSE/OBJECTIVE:The National Death Index (NDI) is an important resource for mortality ascertainment. Methods selected to process NDI search results are rarely described in studies using linked data and can have an impact on resources and mortality ascertainment. We evaluate methods to process NDI search results among a 9/11-exposed cohort-the World Trade Center Health Registry (Registry). METHODS:We describe three approaches to process search results (NDI-recommended cutoff points [NDIc]; National Program of Cancer Registries [NPCR] algorithm, and modified National Institute of Occupational Safety and Health algorithm [mNIOSH]). We calculate percent agreement, positive predictive value, sensitivity, specificity, and quantify the burden of manual review to compare the approaches. RESULTS:Of 51,158 Registry enrollees submitted for linkage, 9449 enrollee-level and 17,909 record-level matches were identified. NPCR and mNIOSH were highly concordant (97.1%); more record pairs required manual review for mNIOSH (mNIOSH: 2.7% and NPCR: 1.8%). NDIc sensitivity was 82.9%, with differences observed by race and ethnicity (Asian: 74.4% and White: 86.1%). CONCLUSIONS:NPCR algorithm minimized false matches and reduced the manual review burden. NDIc had nonrandom distribution of missed matches and low sensitivity. NDI search processing methods have important implications for resulting linked data; measures of linkage quality should be available to data users.

BACKGROUND:Point-of-care ultrasound (POCUS) is becoming widely adopted with increasing accessibility of courses. Little is known about the optimal design of the introductory course or longitudinal training programs targeting hospitalists that are critical to success. METHODS:Hospitalists at four academic sites participated in a two-day introductory course and a longitudinal phase comprising clinical POCUS practice, clip uploading with online feedback, hands-on teaching, and monthly ultrasound conferences. Assessments were performed immediately before and after the two-day course and after 1 year. RESULTS:Knowledge increased from baseline to post two-day course (median score 58 and 85%, respectively, p < 0.001) and decreased slightly at 1 year (median score 81%, p = 0.012). After the two-day introductory course, the median score for hands-on image acquisition skills, the principal metric of participant success, was 75%. After 1 year, scores were similar (median score 74%). Confidence increased from baseline to post two-day course (1.5 to 3.1 on a 4 point Likert scale from Not at all confident (1) to Very confident (4), p < 0.001), and remained unchanged after 1 year (2.73). Course elements correlating with a passing score on the final hands-on test included number of clip uploads (r = 0.85, p,0.001), attendance at hands-on sessions (r = 0.7, p = 0.001), and attendance at monthly conferences (r = 0.50, p = 0.03). CONCLUSIONS:The I-ScaN POCUS training program increased hospitalist knowledge, skill and confidence with maintained skill and confidence after 1 year. Uploading clips and attending hands-on teaching sessions were most correlative with participant success.

BACKGROUND Lyme borreliosis, caused by spirochetes of the Borrelia burgdorferi genospecies complex, is the most commonly reported tickborne infection in North America and those infected may present with cutaneous, cardiac, articular, and neuropsychiatric abnormalities. The protean nature of many of its clinical manifestations presents a diagnostic conundrum. Lyme disease can affect the heart, albeit rarely, with cardiac abnormalities usually manifesting as varying degrees of heart block or arrhythmias. CASE REPORT We present a case of complete heart block in a young man who participated in outdoor activities in a Lyme-endemic area and developed fatigue and palpitations weeks after a flu-like illness. He noticed that his heart rate was low; he had an intermediate suspicious index in Lyme carditis (SILC) score with positive Lyme serologies. His initial electrocardiogram when he presented to the emergency department showed a complete heart block. In this case, he was successfully managed with intravenous ceftriaxone, amoxicillin, and a transcutaneous pacemaker, obviating the need for a permanent pacemaker. CONCLUSIONS Electrocardiographic changes such as heart block and arrhythmias with or without symptoms may be the initial manifestation of Lyme carditis in a patient who may or may not remember a tick bite or have a typical skin rash. The SILC score may assist in recognizing these cases and prompt initiation of antibiotics usually leads to the resolution of these electrocardiographic abnormalities and symptoms that may be present.