Nevin Manimala

Kidney360. 2024 Dec 3. doi: 10.34067/KID.0000000670. Online ahead of print.

ABSTRACT

BACKGROUND: The prevalence of depression is high in the chronic kidney disease (CKD) (20-40%) and dialysis (30-50%) populations. Less is known about how depressive symptoms change over time in patients with CKD.

METHODS: Participants in the Brain in Kidney Disease (BRINK) cohort study completed a depressive symptom questionnaire (PHQ-9) and serum creatinine testing annually. We used linear mixed effects models to examine changes in PHQ-9 scores over time and compared rates of change between participants with different ranges of eGFR impairment and those with normal eGFR.

RESULTS: At baseline, 147 participants had normal eGFR, 424 had impaired eGFR without dialysis dependence, and 31% reported a diagnosis of depression, with a mean baseline PHQ-9 score of 4.3. Participants were followed for up to 5 years. After adjustment for factors associated with depression, mean PHQ-9 scores decreased (improved) by 0.25 points per year (95% confidence interval [CI] 0.07, 0.42) among participants with normal eGFR (>60 ml/min/1.73m2) and by 0.35 points (95% CI 0.14, 0.56), 0.30 points (95% CI 0.13,0.46) and 0.42 points (95% CI 0.06, 0.77) among participants with eGFR of 45 to 59 ml/min/1.73m2, 30 to 44 ml/min/1.73m2, and participants who developed dialysis dependence, respectively. PHQ-9 scores among participants with eGFR <30 ml/min/1.73m2 did not change significantly. We did not observe any statistically significant differences in mean change in PHQ-9 score between participants with any degree of eGFR impairment and those with normal eGFR, nor between participants with dialysis-dependence and those with eGFR of ≤15 ml/min/1.73m2. Participants with a PHQ-9 score ≥5 had 80% greater odds of immediate study attrition than participants with a PHQ-9 score of 0-4.”

CONCLUSIONS: The mean PHQ-9 scores of participants were largely stable over time, and we observed no differences in the change in PHQ-9 scores between those with impaired eGFR and those with normal eGFR.

PMID:39625788 | DOI:10.34067/KID.0000000670

West J Emerg Med. 2024 Nov;25(6):993-999. doi: 10.5811/westjem.18513.

ABSTRACT

OBJECTIVE: Food insecurity is a prevalent social risk among emergency department (ED) patients. Patients who may benefit from food insecurity resources may be identified via ED-based screening; however, many patients experience difficulty accessing resources after discharge. Co-locating resources in or near the ED may improve utilization by patients, but this approach remains largely unstudied. This study characterized the acceptance and use of a food voucher redeemable at a hospital food market for patients who screened positive for food insecurity during their ED visit.

METHODS: This prospective cohort study, conducted at a single county-funded ED, included consecutive adult patients who presented on weekdays between 8 AM-8 PM from July-October 2022 and consented to research participation. We excluded patients who required resuscitation on arrival or could not provide written informed consent in English. Study participants completed a paper version of the two-question Hunger Vital Sign screening tool, administered by research staff. Participants who screened positive received a uniquely numbered $30 food voucher redeemable at the hospital’s co-located food market. Voucher redemption was quantified through regular evaluation of market receipt records at 30-day intervals. The primary outcome was the proportion of redeemed vouchers. Secondary outcomes included the proportion of participants screening positive for food insecurity, proportion of participants accepting vouchers, and associated descriptive statistics.

RESULTS: Of the 396 eligible individuals approached, 377 (95.2%) consented and completed food insecurity screening. Most were middle-aged (median 53 years, interquartile range 30-58 years), 191 were female (50.4%), 242 were Black (63.9%), and 343 were non-Hispanic (91.0%). Of the participants, 228 (60.2%) screened positive for food insecurity and 224 received vouchers (98.2%), of which 86 were redeemed (38.4%) a median of nine days after the ED visit.

CONCLUSION: A high proportion of participants screened positive for food insecurity and accepted food vouchers; however, less than half of all vouchers were redeemed at the co-located food market. These results imply ED food voucher distribution for food insecurity is feasible, but co-location of resources alone may be insufficient in addressing the social risk and alludes to a limited understanding of facilitators and barriers to resource utilization following ED-based social needs screening.

PMID:39625774 | DOI:10.5811/westjem.18513

West J Emerg Med. 2024 Nov;25(6):975-984. doi: 10.5811/westjem.18586.

ABSTRACT

INTRODUCTION: The workload of physicians increased due to the number of patients presenting with suspicion of coronavirus 2019 (COVID-19) and the prolonged wait times in the emergency department during the COVID-19 pandemic. Signal peptide-CUB-EGF domain-containing protein 1 (SCUBE-1) is a protein present in platelets and endothelial cells; it is activated by inflammation from COVID-19 and may be associated with COVID-19’s known thrombotic risk. We aimed to determine whether SCUBE-1 levels are diagnostically correlated in suspected COVID-19 patients, and whether SCUBE-1 correlated with severity of disease and, therefore, might be useful to guide hospitalization/discharge decisions.

METHODS: The suspected COVID-19 patients cared for at tertiary healthcare institutions for one year between May 2021-May 2022 were examined in this study. The subjects were both suspected COVID-19 patients not ultimately found to have COVID-19 and those who were diagnosed with COVID-19. By modifying the disease severity scoring systems present in COVID-19 guidelines in 2021, the COVID-19-positive patient group was classified as mild, moderate, severe, and critical, and compared using the SCUBE-1 levels. Moreover, SCUBE-1 levels were compared between the COVID-19 positive group and the COVID-19 negative group.

RESULTS: A total of 507 patients were considered for the present study. After excluding 175 patients for incomplete data and alternate comorbid organ failure. we report on 332 patients (65.5%). Of these 332 patients, 80 (24.0%) were COVID-19 negative, and 252 (76.0%) were COVID-19 positive. Of 252 (100%) patients diagnosed with COVID-19, 74 (29.4%) were classified as mild, 95 (37.7%) moderate, 45 (17.8%) severe, and 38 (15.1%) critical. The SCUBE-1 levels were statistically different between COVID-19 positive (8.48 ± 7.42 nanograms per milliliter [ng/mL]) and COVID-19 negative (1.86 ± 0.92 ng/mL) patients (P < 0.001). In the COVID-19 positive group, SCUBE-1 levels increased with disease severity (mild = 3.20 ± 1.65 ng/mL, moderate = 4.78 ± 2.26 ng/mL, severe = 13.68 ± 3.95 ng/mL, and critical = 21.87 ± 5.39 ng/mL) (P < 0.001). The initial SCUBE-1 levels of discharged patients were significantly lower than those requiring hospitalization (discharged = 2.89 ng/mL [0.55-8.60 ng/mL]; ward admitted = 7.13 ng/mL [1.38-21.29 ng/mL], and ICU admitted = 21.19 ng/mL [10.58-37.86 ng/mL]) (P < 0.001).

CONCLUSION: The SCUBE-1 levels were found to be differentiated between patients with and without COVID-19 and to be correlated with the severity of illness.

PMID:39625772 | DOI:10.5811/westjem.18586

West J Emerg Med. 2024 Nov;25(6):966-974. doi: 10.5811/westjem.17998.

ABSTRACT

INTRODUCTION: We aimed to assess antibiotic stewardship by quantifying the use of first-dose intravenous (IV) vs oral-only antibiotics and the frequency with which antibiotic class was changed for discharged patients. Secondary aims included the following: evaluation of the relative length of stay (LOS); differences in prescribing patterns between clinician types; differences between academic and community settings; assessment of prescribing patterns among emergency department (ED) diagnoses; and frequency of return visits for patients in each group.

METHODS: This was a retrospective cohort study including patients presenting to EDs with infections who were discharged from our Midwest healthcare system consisting of 17 community hospitals and one academic center. We included infection type, antibiotic class and route of administration, type of infection, LOS, return visit within two weeks, clinician type, and demographics. Data were collected between June 1, 2018-December 31, 2021 and analyzed using descriptive statistics.

RESULTS: We had 77,204 ED visits for patients with infections during the study period, of whom 3,812 received IV antibiotics during their visit. There were more women (62.4%) than men included. Of the 3,812 patients who received IV antibiotics, 1,026 (34.3%) were discharged on a different class of antibiotics than they received. The most common changes were from IV cephalosporin to oral quinolone or penicillin. Patients treated with IV antibiotics prior to discharge had a longer LOS in the ED (median difference of 102 minutes longer for those who received IV antibiotics). There was not a significant difference in the use of IV antibiotics between the academic center and community sites included in the study.

CONCLUSION: Administering IV antibiotics as a first dose prior to oral prescriptions upon discharge is common, as is shifting classes from the IV dose to the oral prescription. This offers an opportunity for intervention to improve antibiotic stewardship for ED patients as well as reduce cost and length of stay.

PMID:39625771 | DOI:10.5811/westjem.17998

West J Emerg Med. 2024 Nov;25(6):917-920. doi: 10.5811/westjem.18579.

ABSTRACT

INTRODUCTION: Previous studies have shown that patients in the emergency department (ED) are frequently given incomplete discharge instructions that are written at least four grade levels above the recommended sixth-grade reading level, leading to poor understanding. Our aims in this study were to implement standardized discharge instructions containing six key components written at a more appropriate reading level for common emergency department (ED) diagnoses to improve patient understanding.

METHODS: We conducted this study in a 20-bed ED at an urban Veteran’s Administration hospital. Data was collected via in-person patient and clinician interviews. Patient interviews were conducted after patients received their discharge instructions. We compared patient responses to clinician responses and marked them as incorrect, partially correct, or correct with a score of 0, 0.5, or 1, respectively. The maximum possible score for each interview was six. Six key components of discharge instructions were asked about: diagnosis; new medications; at-home care; duration of illness; reasons to return; and follow-up. There were 25 patients in the pre-intervention group and 20 in the intervention group with the standardized set of instructions. We performed a Mann-Whitney U test on the total interview scores in the control and intervention groups and conducted a sub-analysis on the individual scores for each of the six key components.

RESULTS: The patients in the intervention demonstrated a statistically significant increase in patient-clinician correlation when compared to the patients in the pre-intervention group overall (P < 0.05), and two of the six key components of the discharge instructions individually showed statistically significant increase in patient-clinician correlation when standardized discharge instructions were used.

CONCLUSION: Patients who received the standardized discharge instructions had improved understanding of their discharge instructions. Future opportunities extending off this pilot study include expanding the number of diagnoses for which standardized instructions are used and investigating patient-centered outcomes related to these instructions.

PMID:39625764 | DOI:10.5811/westjem.18579

West J Emerg Med. 2024 Nov;25(6):907-912. doi: 10.5811/westjem.24863.

ABSTRACT

INTRODUCTION: Coronavirus 2019 (COVID-19) accelerated the need for virtual learning including telesimulation. Many emergency medicine (EM) programs halted in-person simulation and trialed telesimulation, but specifics on its utilization and plans for future use are unknown. Telesimulation has been defined as “a process by which telecommunication and simulation resources are utilized to provide education, training, and/or assessment to learners at an off-site location.” Our objective in this study was to describe the patterns of telesimulation usage in EM residency programs during COVID-19-induced learning restrictions as well as its anticipated future utility.

METHODS: We identified EM simulation leaders via the EMRA Match website, institutional websites, or personal contact with residency coordinators and directors, and invited them to participate by email. Participants completed a confidential, web-based survey consisting of multiple-choice items and one free-response question, developed by our study team with consideration of survey research best practices and Messick’s validity framework. We collected data between January-February 2022. We calculated descriptive statistics for multiple-choice items and examined the free-response answers for common themes.

RESULTS: We obtained contact information for simulation leaders at 139 EM residency programs. Survey response rate was 65% (91/139). During in-person restrictions, 62% (56/91) of programs used telesimulation. Assuming all restrictions lifted, 38% (34/90) of respondents planned to continue to use telesimulation, compared to 9% (8/91) using telesimulation before COVID-19. Most respondents planned to use telesimulation for medical knowledge (26/34, 76%) and communication/teamwork-focused cases (23/34, 68%). In response to the free-response question regarding experience with and plans for use, we identified three major themes: 1) telesimulation is a valuable alternative to in-person learning; 2) telesimulation is an option for learners unable to participate in person; and 3) telesimulation is challenging for procedural education.

CONCLUSION: Despite the relatively limited use of telesimulation in EM residencies prior to COVID-19, an increased number of programs have plans to continue incorporating telesimulation into their curricula. This plan for continued use opens opportunities for further innovation and scholarship within simulation education.

PMID:39625762 | DOI:10.5811/westjem.24863

West J Emerg Med. 2024 Nov;25(6):883-889. doi: 10.5811/westjem.18468.

ABSTRACT

INTRODUCTION: Coronavirus 2019 (COVID-19) has had a devastating impact on mental health and access to addiction treatment in the United States, including in California, which resulted in the highest rates of emergency department visits (ED) for opioid poisoning in 2020. As California slowly returns to pre-pandemic normalcy, it remains uncertain whether the rates of opioid-related events have slowed down over time. We hypothesized that the number of opioid-related ED visits were exacerbated after the period of the COVID-19 pandemic and continue at a high rate in the present.

METHODS: In this analysis we searched the University of California (UC) Health Data Warehouse-a database of electronic health records from six academic medical centers-for opioid related ED visits, identifiying using the following International Classification of Diseases, 10^th Ed, Clinical Modification codes: F11 codes, and T40.0*, T40.1*, T40.2*, T40.3*, T40.4*, T40.6*. Opioid overdose-associated visits were classified by types of opioids involved: heroin (T40.1*); prescription opioids (T40.2* or T40.3*); and synthetic opioids (T40.4*). We performed interrupted time analysis to estimate the immediate (level) change and change-in-time trend (trend change), from before (January 2018-October 2019) and during the pandemic (April 2020-December 2022). Monthly visit rates were evaluated with negative binomial regression adjusted for first-order autoregression and using all-cause ED counts as the offset. We present effect sizes as rate ratios (RR) and 95% confidence intervals (CI), tested at α = .05.

RESULTS: We observed a decrease in overall ED visits from 28,426 to 25,121 visits in December 2019 and June 2021, respectively across all six UC Health Centers. Before COVID-19, we found that ED visit rates steadily increased for all outcomes (P < 0.05) except synthetic opioids. Total opioid-related ED visit rates increased by 15% (RR 1.15, 95% CI 1.02-1.29, P = 0.20) immediately after March 2020 before decreasing by 0.5% every month, albeit without statistical significance (RR .995, 95% CI .991-1.00, P = 0.06). Opioid-related events across the six academic medical centers increase from 232 in December 2019, representing a single month’s total, and peaked at 315 in June 2021. Similar trends were observed with prescription opioid overdoses, with a step increase of 44% (RR 1.44, 95% CI 1.10-1.89, P = .008) before plateauing after March 2020 (RR 1.01, 95% CI .998-1.02, P = 0.12). Specifically, the total number of prescription opioid-related ED visits more than doubled between December 2019 (22 visits) and June 2021 (49 visits). After March 2020, ED visit rates for synthetic opioid overdoses were increasing steadily by 4% every month (RR 1.04, 95% CI 1.02-1.06, P = .001), unlike with heroin, which was observed with an 8% monthly reduction (RR .92, 95% CI .90-.93, P < .001). No immediate increase in visit rates was observed for either opioid.

CONCLUSION: While opioid-related ED admissions among the UC health centers showed an overall decrease, prescription and synthetic opioid overdoses remained significantly higher than pre-pandemic trends as of December 2022. A multilevel approach to improve awareness of new opioid health policies could ameliorate these alarming rises in the post-pandemic era.

PMID:39625758 | DOI:10.5811/westjem.18468

West J Emerg Med. 2024 Nov;25(6):869-874. doi: 10.5811/westjem.18569.

ABSTRACT

INTRODUCTION: As fentanyl has become more readily available, opioid-related morbidity and mortality in the United States has increased dramatically. Preliminary studies suggest that high-affinity, partial mu-opioid receptor agonists such as the combination product buprenorphine-naloxone may reduce mortality from overdose and promote remission. With the escalating prevalence of opioid use disorder (OUD), it is essential to evaluate the effectiveness of opioid agonists like buprenorphine-naloxone. This study examines mortality and remission rates for OUD patients prescribed buprenorphine-naloxone to determine the efficacy of this treatment toward these outcomes.

METHODS: We carried out a retrospective analysis using the US Collaborative Network database in TriNetX, examining de-identified medical records from nearly 92 million patients across 56 healthcare organizations. The study spanned the years from January 1, 2017-May 13, 2022. Cohort 1 included OUD patients who began buprenorphine-naloxone treatment within one-year post-diagnosis, while Cohort 2, the control group, consisted of OUD patients who were not administered buprenorphine. The study measured mortality and remission rates within a year of the index event, incorporating propensity score matching for age, gender, and race/ethnicity.

RESULTS: Prior to propensity matching, we identified a total of 221,967 patients with OUD. Following exclusions, 61,656 patients treated with buprenorphine-naloxone showed 34% fewer deaths within one year of diagnosis compared to 159,061 patients who did not receive buprenorphine (2.6% vs 4.0%; relative risk [RR] 0.661; 95% confidence interval [CI] 0.627-0.698; P < 0.001). The remission rate was approximately 1.9 times higher in the buprenorphine-naloxone group compared to the control group (18.8% vs 10.1%; RR 1.862; 95% CI 1.812-1.914; P < 0.001). After propensity matching, the effect on mortality decreased but remained statistically significant (2.6% vs 3.0%; RR 0.868; 95% CI 0.813-0.927; P < 0.001) and the remission rate remained consistent (18.8% vs 10.4%; RR 1.812; 95% CI 1.750-1.876; P < 0.001). Number needed to treat for benefit was 249 for death and 12 for remission.

CONCLUSION: Buprenorphine-naloxone was associated with significantly reduced mortality and increased remission rates for patients with opioid use disorder and should be used as a primary treatment. The recognition and implementation of treatment options like buprenorphine-naloxone is vital in alleviating the impact of OUD.

PMID:39625756 | DOI:10.5811/westjem.18569

J Am Coll Health. 2024 Dec 3:1-12. doi: 10.1080/07448481.2024.2404945. Online ahead of print.

ABSTRACT

Objective: Examine associations between ultra-processed food (UPF) intake and diet quality (DQ) in college students. Participants: Analysis included 695 participants ages 18-39 years. Methods: Dietary data were collected using the online Diet History Questionnaires II and III. The Healthy Eating Index 2020 (HEI-2020) adult score assessed DQ. NOVA classification was used to identify UPFs. Multivariable linear regression was used to examine associations between %EI from UPF and HEI-2020 total and component scores, controlling for gender, race, smoking, campus meal plan, and EI. Results: Mean age was 19.2 years. In fully adjusted models a statistically significant inverse association was found between %EI from UPF and HEI-2020 total scores (F = 37.81, p < 0.001, R²=0.26), all HEI adequacy scores except whole grains (not significant) and dairy (weak positive association), and for saturated fat, refined grains, and sodium scores. Conclusions: Addressing UPF intake in young adult college students could be a potential strategy to improve DQ.

PMID:39625752 | DOI:10.1080/07448481.2024.2404945

JMIR Public Health Surveill. 2024 Dec 3;10:e59844. doi: 10.2196/59844.

ABSTRACT

BACKGROUND: Population-based databases are valuable for perinatal research. The California Department of Health Care Access and Information (HCAI) created a linked birth file covering the years 1991 through 2012. This file includes birth and fetal death certificate records linked to the hospital discharge records of the birthing person and infant. In 2019, the University of California Study of Outcomes in Mothers and Infants received approval to create similar linked birth files for births from 2011 onward, with 2 years of overlapping birth files to allow for linkage comparison.

OBJECTIVE: This paper aims to describe the University of California Study of Outcomes in Mothers and Infants linkage methodology, examine the linkage quality, and discuss the benefits and limitations of the approach.

METHODS: Live birth and fetal death certificates were linked to hospital discharge records for California infants between 2005 and 2020. The linkage algorithm includes variables such as birth hospital and date of birth, and linked record selection is made based on a “link score.” The complete file includes California Vital Statistics and HCAI hospital discharge records for the birthing person (1 y before delivery and 1 y after delivery) and infant (1 y after delivery). Linkage quality was assessed through a comparison of linked files and California Vital Statistics only. Comparisons were made to previous linked birth files created by the HCAI for 2011 and 2012.

RESULTS: Of the 8,040,000 live births, 7,427,738 (92.38%) California Vital Statistics live birth records were linked to HCAI records for birthing people, 7,680,597 (95.53%) birth records were linked to HCAI records for the infant, and 7,285,346 (90.61%) California Vital Statistics birth records were linked to HCAI records for both the birthing person and the infant. The linkage rates were 92.44% (976,526/1,056,358) for Asian and 86.27% (28,601/33,151) for Hawaiian or Pacific Islander birthing people. Of the 44,212 fetal deaths, 33,355 (75.44%) had HCAI records linked to the birthing person. When assessing variables in both California Vital Statistics and hospital records, the percentage was greatest when using both sources: the rates of gestational diabetes were 4.52% (329,128/7,285,345) in the California Vital Statistics records, 8.2% (597,534/7,285,345) in the HCAI records, and 9.34% (680,757/7,285,345) when using both data sources.

CONCLUSIONS: We demonstrate that the linkage strategy used for this data platform is similar in linkage rate and linkage quality to the previous linked birth files created by the HCAI. The linkage provides higher rates of crucial variables, such as diabetes, compared to birth certificate records alone, although selection bias from the linkage must be considered. This platform has been used independently to examine health outcomes, has been linked to environmental datasets and residential data, and has been used to obtain and examine maternal serum and newborn blood spots.

PMID:39625748 | DOI:10.2196/59844