Faculty Bibliography
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department:Medicine. General Internal Medicine
recentyears:2
school:SOM
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14527
Development and Validation of a Survival Calculator for Hospitalized Patients with COVID-19
BACKGROUND:Chinese studies reported predictors of severe disease and mortality associated with coronavirus disease 2019 (COVID-19). A generalizable and simple survival calculator based on data from US patients hospitalized with COVID-19 has not yet been introduced. OBJECTIVE:Develop and validate a clinical tool to predict 7-day survival in patients hospitalized with COVID-19. DESIGN/METHODS:Retrospective and prospective cohort study. SETTING/METHODS:Thirteen acute care hospitals in the New York City area. PARTICIPANTS/METHODS:Adult patients hospitalized with a confirmed diagnosis of COVID-19. The development and internal validation cohort included patients hospitalized between March 1 and May 6, 2020. The external validation cohort included patients hospitalized between March 1 and May 5, 2020. MEASUREMENTS/METHODS:Demographic, laboratory, clinical, and outcome data were extracted from the electronic health record. Optimal predictors and performance were identified using least absolute shrinkage and selection operator (LASSO) regression with receiver operating characteristic curves and measurements of area under the curve (AUC). RESULTS:The development and internal validation cohort included 11 095 patients with a median age of 65 years [interquartile range (IQR) 54-77]. Overall 7-day survival was 89%. Serum blood urea nitrogen, age, absolute neutrophil count, red cell distribution width, oxygen saturation, and serum sodium were identified as the 6 optimal of 42 possible predictors of survival. These factors constitute the NOCOS (Northwell COVID-19 Survival) Calculator. Performance in the internal validation, prospective validation, and external validation were marked by AUCs of 0.86, 0.82, and 0.82, respectively. LIMITATIONS/CONCLUSIONS:All participants were hospitalized within the New York City area. CONCLUSIONS:The NOCOS Calculator uses 6 factors routinely available at hospital admission to predict 7-day survival for patients hospitalized with COVID-19. The calculator is publicly available at https://feinstein.northwell.edu/NOCOS.
PMCID:7276996
PMID: 32511640
ISSN: n/a
CID: 4996192
Journal of thoracic & cardiovascular surgery. 2020:159(6):2230-2240.e15.DOI: 10.1016/j.jtcvs.2019.06.040
Cost-effectiveness of coronary artery bypass grafting plus mitral valve repair versus coronary artery bypass grafting alone for moderate ischemic mitral regurgitation
OBJECTIVE:The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. METHODS:We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. RESULTS:In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; -0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [-3866 to 56,826]) and quality-adjusted life years showed no difference (-0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. CONCLUSIONS:The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.
PMID: 31375378
ISSN: 1097-685x
CID: 5451272
When Predictive Models Collide
PMID: 32543898
ISSN: 2473-4276
CID: 4517842
Slow-pathway visualization by using voltage-time relationship: a novel technique for identification and fluoroless ablation of atrioventricular nodal reentrant tachycardia
BACKGROUND:Atrioventricular nodal reentrant tachycardia (AVNRT) is treatable by catheter ablation. Advances in mapping-system technology permit fluoroless workflow during ablations. As national practice trends toward fluoroless approaches, easily obtained, reproducible methods of slow-pathway identification and ablation become increasingly important. We present a novel method of slow-pathway identification and initial ablation results from this method. METHODS AND RESULTS/RESULTS:We examined AVNRT ablations performed at our institution over a 12-month period. In these cases, the site of the slow pathway was predicted by latest activation in the inferior triangle of Koch during sinus rhythm. Ablation was performed in this region. Proximity of the predicted site to the successful ablation location, complication rates, and patient outcomes were recorded. Junctional rhythm was seen in 40/41 ablations (98%) at the predicted site (mean, 1.3 lesions and median, 1 lesion per case). One lesion was defined as 5mm of ablation. The initial ablation was successful in 39/41 cases (95%); in 2 cases, ≥2 echo beats were detected after the initial ablation, necessitating further lesion expansion. In 8/41 cases (20%), >1 lesion was placed during initial ablation before attempted reinduction. Complications included 1 transient heart block and 1 transient PR prolongation. During follow up (median, day 51), 1 patient had lower-extremity deep-vein thrombosis and pulmonary embolus, and 1 had a lower-extremity superficial venous thrombosis. There was 1 tachycardia recurrence, which prompted a redo ablation. CONCLUSIONS:Mapping-system detection of late-activation, low-amplitude voltage during sinus rhythm provides an objective, fluoroless means of identifying the slow pathway in typical AVNRT. This article is protected by copyright. All rights reserved.
PMID: 32270564
ISSN: 1540-8167
CID: 4377552
Molecular and clinical epidemiology of carbapenem-resistant Enterobacterales in the USA (CRACKLE-2): a prospective cohort study
BACKGROUND:Carbapenem-resistant Enterobacterales (CRE) are a global threat. We aimed to describe the clinical and molecular characteristics of Centers for Disease Control and Prevention (CDC)-defined CRE in the USA. METHODS:CRACKLE-2 is a prospective, multicentre, cohort study. Patients hospitalised in 49 US hospitals, with clinical cultures positive for CDC-defined CRE between April 30, 2016, and Aug 31, 2017, were included. There was no age exclusion. The primary outcome was desirability of outcome ranking (DOOR) at 30 days after index culture. Clinical data and bacteria were collected, and whole genome sequencing was done. This trial is registered with ClinicalTrials.gov, number NCT03646227. FINDINGS/RESULTS:1040 patients with unique isolates were included, 449 (43%) with infection and 591 (57%) with colonisation. The CDC-defined CRE admission rate was 57 per 100 000 admissions (95% CI 45-71). Three subsets of CDC-defined CRE were identified: carbapenemase-producing Enterobacterales (618 [59%] of 1040), non-carbapenemase-producing Enterobacterales (194 [19%]), and unconfirmed CRE (228 [22%]; initially reported as CRE, but susceptible to carbapenems in two central laboratories). Klebsiella pneumoniae carbapenemase-producing clonal group 258 K pneumoniae was the most common carbapenemase-producing Enterobacterales. In 449 patients with CDC-defined CRE infections, DOOR outcomes were not significantly different in patients with carbapenemase-producing Enterobacterales, non-carbapenemase-producing Enterobacterales, and unconfirmed CRE. At 30 days 107 (24%, 95% CI 20-28) of these patients had died. INTERPRETATION/CONCLUSIONS:Among patients with CDC-defined CRE, similar outcomes were observed among three subgroups, including the novel unconfirmed CRE group. CDC-defined CRE represent diverse bacteria, whose spread might not respond to interventions directed to carbapenemase-producing Enterobacterales. FUNDING/BACKGROUND:National Institutes of Health.
PMID: 32151332
ISSN: 1474-4457
CID: 4348732
Age Is Just a Number-Frailty Associates With Outcomes of Patients With Inflammatory Bowel Disease [Comment]
PMID: 32247690
ISSN: 1528-0012
CID: 4959462
THE DUAL EFFICACY OF PHARMACOTHERAPY WITH INTRAGASTRIC BALLOONS FOR SUSTAINED WEIGHT LO [Meeting Abstract]
In their relative infancy, intragastric balloons (IGB) offer a solution to patients who do not qualify for bariatric surgery due to their body mass index (BMI) or those reticent about major surgery with a promise of 10-15% of total body weight loss (TBWL%). Given a short implantation period of 6 months, weight regain following IGB removal has been commonly noted. This caveat prompted analysis of the addition of weight loss medications for improved efficacy in achieving sustained weight loss results post-IGB removal. In a single-center retrospective analysis from 2015 to 2018, 18 patients (mean age 39.72, 5 males, 13 females) with a saline-filled single intragastric balloon were evaluated for 12 months following IGB insertion. Exactly half of the patients (n=9) were on weight loss medications before, during, or after placement of IGB (IGB-M cohort) to compare to patients with IGBs only (IGB-O cohort). All patients were >18 years old, non-pregnant, and with no previous bariatric surgeries. Data was collected at 0, 3, 6, and 12 month intervals. Mean weight at baseline was 198.33lbs and 223lbs (p=0.814) and mean BMI was 32.79 kg/m2 versus 35.5 kg/m2 (p=0.546), in the IGB-O cohort versus the IGB-M cohort, respectively. At six months, the TBWL% in the IGB-O cohort versus the IGB-M cohort was 12.7% versus 13.1%, while mean BMI was 28.42 versus 31.62 (p=0.645), respectively. Attrition rate was 11.1% by 6 months and 72.2% by 12 months for both cohorts combined. At 12 months, TBWL% in the IGB-O cohort versus IGB-M cohort was 2.8% and 10.7%, while mean BMI was 33.77 and 29.17 (p=0.4), respectively. The most common class of medications utilized were glucagon-like peptide-1 (GLP-1) agonists (37.5%). Phentermine was the single most commonly prescribed medication (25%). The mean number of medications needed for a patient was 1.8. The TBWL% at six months demonstrated a slightly greater 0.4 TBWL% in the IGB-M cohort. This meant weight loss achieved with a balloon or weight loss pharmacotherapy was essentially equivalent in our study at the time of IGB removal at 6 months. However, a stark variance is noted at the 12 month mark in the IGB-O cohort with patients either partially regaining their previously lost weight or losing marginally further with a mean 2.8 TBWL% post IGB removal. Comparatively, the IGB-M cohort patients continued their weight loss or maintained their initial weight loss with a 10.7% TBWL creating a 7.9 TBWL% difference at the 12 month follow up between the two arms. Administration of medications might increase follow-up post IGB removal and decrease attrition rates. Results illustrate a two-pronged approach of combining weight loss medications with IGBs would culminate in a more clinically significant TBWL% with long term sustainability post IGB removal. Larger multi-center studies are recommended in order to achieve significant conclusions. [Formula presented] [Formula presented]
Copyright
Copyright
EMBASE:2006056286
ISSN: 1097-6779
CID: 4472112
Novel peer-facilitated method to decrease burnout and enhance professional development: the READ-SG prospective cohort study [Comment]
PMID: 32139470
ISSN: 1469-0756
CID: 4959452
Choosing Wisely in the COVID-19 Era: Preventing Harm to Healthcare Workers
PMCID:7289510
PMID: 32490804
ISSN: 1553-5606
CID: 4482202
Improving Depression Screening in Underserved Populations in a Large Urban Academic Primary Care Center: A Provider-Centered Analysis and Approach
Screening for depression is paramount to identify patients with depression and link them to care, yet only 29% of patients in the primary care center (PCC) were screened for depression in 2016. A baseline survey identified provider barriers to depression screening, including lack of time, support staff, and referral resources. The purpose of this project was to increase depression screening in the PCC using the Patient Health Questionnaire (PHQ-2/9). The authors created an educational program for staff and providers that included referral resources, treatment guidelines, and a decision-support tool in the electronic medical record. A retrospective chart review was performed, from January 2016 to June 2017, to determine the percentage of patients who received annual depression screening. During the program, the PCC saw an increase in depression screening rates. Thus, it is possible to overcome barriers to depression screening in a primary care setting by providing resources and education to clinicians.
PMID: 31701768
ISSN: 1555-824x
CID: 5345552
