Thongprayoon, Charat

Background: This study aimed to determine the rates of inpatient palliative care service use and assess the impact of palliative care service use on in-hospital treatments and resource utilization in hospital admissions for hepatorenal syndrome. Methods: Using the National Inpatient Sample, hospital admissions with a primary diagnosis of hepatorenal syndrome were identified from 2003 through 2014. The primary outcome of interest was the temporal trend and predictors of inpatient palliative care service use. Logistic and linear regression was performed to assess the impact of inpatient palliative care service on in-hospital treatments and resource use. Results: Of 5571 hospital admissions for hepatorenal syndrome, palliative care services were used in 748 (13.4%) admissions. There was an increasing trend in the rate of palliative care service use, from 3.3% in 2003 to 21.1% in 2014 (p < 0.001). Older age, more recent year of hospitalization, acute liver failure, alcoholic cirrhosis, and hepatocellular carcinoma were predictive of increased palliative care service use, whereas race other than Caucasian, African American, and Hispanic and chronic kidney disease were predictive of decreased palliative care service use. Although hospital admission with palliative care service use had higher mortality, palliative care service was associated with lower use of invasive mechanical ventilation, blood product transfusion, paracentesis, renal replacement, vasopressor but higher DNR status. Palliative care services reduced mean length of hospital stay and hospitalization cost. Conclusion: Although there was a substantial increase in the use of palliative care service in hospitalizations for hepatorenal syndrome, inpatient palliative care service was still underutilized. The use of palliative care service was associated with reduced resource use.

Abstract Background: Previous studies have shown that telemedicine is an effective alternative method for health care delivery. The COVID-19 pandemic has acutely stimulated expansion of telemedicine across the country. This study aimed to determine characteristics of telehealth visit and short term HbA1c outcome in patients with diabetes mellitus in endocrinology clinic during the COVID-19 pandemic. Methods: A single center retrospective chart review was conducted in all patients seen in endocrinology clinic for diabetes mellitus between 5/27/2020–7/20/2020. Data were extracted from electronic medical record. The primary research question is percentage of patients who achieved HbA1C ≤ 8% at 3 month follow up. Secondary research questions are characteristic of patients and clinic visits, diabetic technology usage, 3 month follow up mean HbA1c and HbA1c change. This project was approved by the institutional review boards. Results: Two hundred and six diabetic patients were seen: 72 (35%) in person, 49 (24%) phone visit, and 85 (41%) VDO visit. Mean age for patients adopted in person visit was 57 (SD 15) years, phone visit was 68 (SD 13) years and VDO visit was 54 (SD 18) years, p &lt;0.001. Male percentage for in person, phone and VDO visit was 44%, 59% and 61% respectively, p 0.09. New consult visit percentage for in person, phone and VDO visit was 7%, 2% and 5% respectively, p 0.46. Percentage of patients using insulin pump or continuous glucose monitoring for in person, phone and VDO visit was 33%, 43% and 54%, respectively, p 0.03. Baseline HbA1c was done in 89% (64/72) in person, 45% (22/49) phone and 52% (44/85) VDO visit. Among patients who had baseline HbA1c, average HbA1c was 8.6% (SD 1.8) for in person visit, 8.0% (SD 1.1) for phone visit and 8.1% (SD 1.8) for VDO visit, p 0.25. At 3 months, HbA1c was done in 38% of patients who had in person visit, 36% phone visit, and 43% VDO visit. Among patients who had 3 month follow up HbA1c, HbA1c ≤ 8% was achieved in 50%, 61% and 69% for in person, phone and VDO respectively, p 0.56. Mean 3 month follow up HbA1c was 8.1% (SD 1.3), 7.7% (SD 0.9) and 7.8% (SD 1.6) for in-person, phone and VDO visit respectively, p 0.47. Comparing mean HbA1c in patients who had both baseline and 3 month follow up HbA1c, changes were significant for in person visit 9.1% to 8.1% (p 0.01) and VDO visit 8.7% to 7.6% (p 0.01). No significant change in 3 month follow up HbA1c was observed in phone visit, 7.7% to 7.6% (p 0.88). Conclusions: This retrospective study showed that during the COVID-19 pandemic, no differences in short term HbA1c outcome (3 month follow up mean HbA1c and percentage of patients who achieved HbA1c ≤ 8%) were observed among patients who adopted in-person and telehealth visit. Patients who adopted phone visit appeared to be older; and there was more diabetic technology usage (insulin pump or continuous glucose monitoring) among patients who adopted telehealth (phone and VDO) compared to in person visit.

Background: Antidepressants are one of the most prescribed medications, particularly for patients with mental disorders. Nevertheless, there are still limited data regarding the risk of ventricular arrhythmia (VA) and sudden cardiac death (SCD) associated with these medications. Thus, we performed systemic review and meta-analysis to characterize the risks of VA and SCD among patients who used common antidepressants. Methods: A literature search for studies that reported risk of ventricular arrhythmias and sudden cardiac death in antidepressant use from MEDLINE, EMBASE, and Cochrane Database from inception through September 2020. A random-effects model network meta-analysis model was used to analyze the relation between antidepressants and VA/SCD. Surface Under Cumulative Ranking Curve (SUCRA) was used to rank the treatment for each outcome. Results: The mean study sample size was 355,158 subjects. Tricyclic antidepressant (TCA) patients were the least likely to develop ventricular arrhythmia events/sudden cardiac deaths at OR 0.24, 0.028–1.2, OR 0.32 (95% CI 0.038–1.6) for serotonin and norepinephrine reuptake inhibitors (SNRI), and OR 0.36 (95% CI 0.043, 1.8) for selective serotonin reuptake inhibitors (SSRI), respectively. According to SUCRA analysis, TCA was on a higher rank compared to SNRI and SSRI considering the risk of VA/SCD. Conclusion: Our network meta-analysis demonstrated the low risk of VA/SCD among patients using antidepressants for SNRI, SSRI and especially, TCA. Despite the relatively lowest VA/SCD in TCA, drug efficacy and other adverse effects should be taken into account in patients with mental disorders.

Background: Ranolazine has the potential to prevent atrial fibrillation (AF) and plays a role in rhythm control strategy for atrial fibrillation in various clinical settings. However, data on the use of ranolazine in patients with left ventricular (LV) systolic dysfunction are limited. The aims of this meta-analysis of randomized clinical trials are to investigate the efficacy and safety of ranolazine in AF patients with LV systolic dysfunction. PubMed and the Cochrane Database of Systematic Reviews were searched until July 2020. The efficacy outcomes included the incidence of new-onset AF, the rate of sinus rhythm restoration, and the time until sinus rhythm restoration. Safety endpoints were at death, and any adverse events were reported in the enrolled studies. We initially identified 204 studies and finally retrieved 5 RCTs. Three studies were analyzed in the meta-analysis. Among AF patients with LV systolic dysfunction, our meta-analysis showed that the combination of ranolazine to amiodarone significantly increased the sinus rhythm restoration rate compared to amiodarone alone (risk ratio (RR) 2.87, 95% confidence interval (CI) 2.48–3.32). Moreover, the time to sinus rhythm restoration was 2.46 h shorter in the ranolazine added to amiodarone group (95% CI: 2.27–2.64). No significant adverse events and proarrhythmias in the ranolazine group were identified. In conclusion, in AF patients with LV systolic dysfunction, ranolazine as an add-on therapy to amiodarone potentiates and accelerates the conversion of AF to sinus rhythm. Moreover, ranolazine shows good safety profiles. Further studies to investigate the effectiveness of ranolazine in the prevention of new-onset AF among patients with LV systolic dysfunction are needed.

Chronic kidney disease (CKD) is a common clinical problem affecting more than 800 million people with different kidney diseases [...]

Catheter-related bloodstream infection (CRBSI) with hemodialysis catheters are associated with increased mortality, morbidity and pose significant financial burden on healthcare. Antibiotic and antimicrobial locking solutions are effective in reducing risk of CRBSI. From inception to April 2020, we looked for relevant clinical controlled trials throughout the following databases: EBSCO, PubMed, Cochrane CENTRAL, MEDLINE, EMBASE, clinicaltrial.gov, and Google Scholar performing a metanalysis comparing antibiotic and antimicrobial lock solutions to heparin. Twenty-six studies with 4,967 patients reported the incidence of catheter-related bacteremia (CRB). The overall pooled risk ratio (RR) showed that the intervention group was associated with a significantly lower incidence of CRB by 30% compared with heparin (RR = 0.30, 95% confidence interval [CI] [0.25, 0.36], p < 0.001). Subgroup analysis showed that administration of antibiotic regimens led to a decreased risk of CRB episodes by 28% compared with the heparin group (RR = 0.28, 95% CI [0.21, 0.37], p < 0.0001). Antimicrobial solutions was associated with reduced risk of CRB by 32% compared with patients of the control group (RR = 0.32, 95% CI [0.25, 0.41], p < 0.0001). A test of subgroup differences was revealed no significant favoring of any of the two interventions. Both antibiotic and antimicrobial solutions are effective in reducing CRBSI.

SUMMARY Background This study aimed to determine the incidence, as well as evaluate risk factors, and impact of gastrointestinal bleeding on outcomes and resource use in patients admitted for salicylate poisoning. Methods We used the National Inpatient Sample to construct a cohort of patients hospitalized primarily for salicylate poisoning from 2003 to 2014. We compared clinical characteristics, in-hospital treatments, outcomes and resource use between salicylate poisoning patients with and without gastrointestinal bleeding. Results Of 13 805 hospital admissions for salicylate poisoning, gastrointestinal bleeding occurred in 482 (3.5%) admissions. The risk factors for gastrointestinal bleeding included older age, history of atrial fibrillation and cirrhosis. After adjusting for difference in baseline characteristics, patients with gastrointestinal bleeding required more gastric lavage, gastrointestinal endoscopy, invasive mechanical ventilation and red blood cell transfusion. Gastrointestinal bleeding was significantly associated with increased risk of anemia, circulatory, liver and hematological failure but was not significantly associated with increased in-hospital mortality. The length of hospital stay and hospitalization cost was significantly higher in patients with gastrointestinal bleeding. Conclusion Gastrointestinal bleeding occurred in about 4% of patients admitted for salicylate poisoning. Gastrointestinal bleeding was associated with higher morbidity and resource use but not mortality.

Abstract Background: Cardiac dyssynchronization is the proposed mechanism for pacemaker-induced cardiomyopathy. The standard of treatment is biventricular pacing. Left bundle branch pacing and His bundle pacing are novel interventions that imitate the natural conductionof the heart with, theoretically, less interventricular dysynchrony. One of the surrogate markers of interventricular synchrony is QRS duration. Our study aimed to compare the change of QRS duration before and after implantation between types of cardiac implantable electronic device (CIED): left bundle branch pacing versus His bundle pacing versus biventricular pacing and conventional right ventricular pacing. Methods: A literature search for studies that reported an interval change of QRS duration after CIED implantation was conducted utilizing the MEDLINE, EMBASE, and Cochrane databases. All relevant work through September 2020 from these databases was included in this analysis. A random-effects model network meta-analysis was used to analyze QRS duration changes (i.e., electrical cardiac synchronization) across different CIED implantations. Results: The mean study sample size, from 16 included studies, was 185 subjects. According to SUCRA analysis for the studies analyzed, the His bundle pacing intervention resulted in the most dramatic decline in QRS duration (mean difference -53 ms, 95% CI -67, -39), followed by left bundle branch pacing (mean difference -46 ms, 95% CI -60, -33) and biventricular pacing (mean difference -19 ms, 95% CI -37, -1.8), when compared to conventional right ventricle apical lead placement. Conclusion: Our network meta-analysis found that His bundle branch pacing devices have the greatest effect on QRS duration reduction after implantation, followed by left bundle branch pacing. Physiologic pacing interventions result in improved electrocardiography markers of cardiac synchronicity, narrower QRS duration, and might lower electromechanical dyssynchrony.

Introduction As percutaneous coronary intervention (PCI) technologies have been far improved, we hence conducted an updated systemic review and meta-analysis to determine the comparability between coronary artery bypass graft (CABG) and PCI with drug-eluting stent (DES) in ESRD patients. Methods We comprehensively searched the databases of MEDLINE, EMBASE, PUBMED and the Cochrane from inception to January 2020. Included studies were published observational studies that compared the risk of cardiovascular outcomes among dialysis patients with CABG and DES. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. Subgroup analyses and meta-regression were performed to explore heterogeneity. Results Thirteen studies were included in this analysis, involving total 56 422 (CABG 21 740 and PCI 34 682). Compared with DES, our study demonstrated CABG had higher 30-day mortality [odds ratio (OR) 3.85, P = 0.009] but lower cardiac mortality (OR 0.78, P < 0.001), myocardial infarction (OR 0.5, P < 0.001) and repeat revascularization (OR 0.35, P < 0.001). No statistical differences were found between CABG and DES for long-term mortality (OR 0.92, P = 0.055), composite outcomes (OR 0.88, P = 0.112) and stroke (OR 1.49, P = 0.457). Meta-regression suggested diabetes and the presence of left main coronary artery disease as an effect modifier of long-term mortality. Conclusion PCI with DES shared similar long-term mortality, composite outcomes and stroke outcomes to CABG among dialysis patients but still was associated with an improved 30-day survival . However, CABG had better rates of myocardial infarction, repeat revascularization and cardiac mortality.

Background: This study aimed to evaluate the risk factors for circulatory shock and its impact on outcomes in patients hospitalized for salicylate intoxication. Methods: We used the National Inpatient Sample to identify patients hospitalized primarily for salicylate intoxication from 2003–2014. Circulatory shock was identified based on hospital diagnosis code for any type of shock or hypotension. We compared clinical characteristics, in-hospital treatments, outcomes, and resource use between patients with and without circulatory shock associated with salicylate intoxication. Results: Of 13,805 hospital admissions for salicylate intoxication, circulatory shock developed in 484 (4%) admissions. Risk factors for development of circulatory shock included older age, female sex, concurrent psychotropic medication overdose, anemia, congestive heart failure, volume depletion, rhabdomyolysis, seizure, gastrointestinal bleeding, and sepsis. Circulatory shock was significantly associated with increased odds of any organ failure and in-hospital mortality. Length of hospital stay and hospitalization cost was significantly higher in patients with circulatory shock. Conclusion: Approximately 4% of patients admitted for salicylate intoxication developed circulatory shock. Circulatory shock was associated with worse clinical outcomes and increased resource use.