College of Medicine

: Anemia at Discharge and Risk of Readmission in Elderly Patients; Summary: Title: Anemia at Discharge and Risk of Readmission in Elderly Patients Authors: Yeshanew Teklie MD, Niraj Patel MD; Victoria Campdesuner DO; Kayla Marini DO; Yorlenis Rodriguez DO; Karen M. Hamad MD, FAAP, FACP; Mary E. Geary PhD, RN; and Wilhelmine Wiese-Rometsch MD, FACPAffiliation: Florida State University Internal Medicine Residency Program at Sarasota Memorial Hospital, 1700 South Tamiami Trail, Sarasota FL 34239, 941-917-7799Type of Project: Practice-based Quality ImprovementIntroduction: Anemia is defined by the World Health Organization (WHO) as a hemoglobin (Hb) concentration less than 12.0 g/dL for females and less than 13.0 g/dL for males. Objective of this quality improvement initiative was to test if anemia independently is associated with readmission in elderly patients discharged from the medicine service of a community teaching hospital. Methods: We conducted a retrospective cohort study declared exempt by our Institutional Review Board involving electronic medical record data from patients at least 65 years old hospitalized between September 2009 and June 2019 discharged not to hospice care. Severity of anemia classified by the WHO was applied for Hb concentrations obtained at hospital discharge for females as mild (11.0 – 11.9 g/dL), moderate (8.0 – 10.9 g/dL), severe (<8.0 g/dL); and males as mild (11.0 - 12.9 g/dL), moderate (8.0 - 10.9 g/dL), severe (<8.0 g/dL). Time to readmission after index hospitalization within 30d, 90d, and 180d with mild, moderate, severe, or no anemia was compared using Kaplan Meier survival curves with covariates (age; sex; multiple chronic conditions; length of stay; APR-DRG Severity of Illness and Risk of Mortality; and discharge destination) controlled using Cox Proportional Hazard modeling with relative impact assessed using Random Forest modeling. Readmission after 180d was considered a new index hospitalization. Continuous variables summarized as mean (SD) or median (interquartile range) were contrasted using Kruskal-Wallis ANOVA. Categorical variables summarized as proportions were compared using chi square or Fisher exact test. Statistical tests were two-tailed with p<.05 considered significant.Findings: Among 13,526 inpatients with 18,793 discharges median age of 78 (14) years was statistically similar by sex (49% females, 51% males) exhibiting an anemia distribution of no (31.0%), mild (20.5%), moderate (47.1%) and severe (1.4%). Race distributed as 89.9% white; 5.9% African American or Black; and 4.2% Other. Females differentiated distribution across anemia spectrum at no (95.7%) (p<0.001), mild (26.4%) (p<0.001), moderate (51.0%) and severe (43.5%). No, mild, moderate and severe anemia corrected for putative confounders impacted (p<0.001) respectively cumulative risk of readmission at 30 d (7.0%, 7.9%, 17.2%, 21.3%), 90 d (12.0%, 15.3%, 28.1%, 34.8%) and 180 d (16.4%, 20.7%, 34.4%, 42.6%).Conclusion: An essential patient-centric question is whether anemia in elderly inpatients affects poor outcomes and/or whether anemia is a surrogate marker for underlying overt and/or subclinical disease(s). Although present quality improvement initiative was not designed to unravel mechanisms of anemia, we controlled for putative severity of illness confounders while demonstrating readmission risk escalating with severity of anemia. Implications for Practice: Findings herald readmission risk associated with “no anemia” as defined by the World Health Organization. Tailored anemia care could offer clinical advantages to mitigate risk for readmission.Reference: WHO. Hemoglobin concentrations for the diagnosis of anemia. Accessed May 16, 2020 at https://www.who.int/vmnis/indicators/haemoglobin.pdf, Keywords: Discharge Anemia, Risk of Readmission, Elderly Anemia

: Change In Five-factor Model Personality Traits During The Acute Phase Of The Coronavirus Pandemic; The rapid spread of the coronavirus and the strategies to slow it have disrupted just about every aspect of our lives. Such disruption may be reflected in changes in psychological function. The present study used a pre-posttest design to test whether Five Factor Model personality traits changed with the coronavirus outbreak in the United States. Participants (N= 2,137) were tested in early February 2020 and again during the President's 15 Days to Slow the Spread guidelines. In contrast to the preregistered hypotheses, Neuroticism decreased across these six weeks, particularly the facets of Anxiety and Depression, and Conscientiousness did not change. Interestingly, there was some evidence that the rapid changes in the social context had changed the meaning of an item. Specifically, an item about going to work despite being sick was a good indicator of conscientiousness before COVID-19, but the interpretation of it changed with the pandemic. In sum, the unexpected small decline in Neuroticism suggests that, during the acute phase of the coronavirus outbreak, feelings of anxiety and distress may be attributed more to the pandemic than to one's personality., impact, age, life events, The publisher's version of record is availible at https://doi.org/10.1371/journal.pone.0237056

: Clinical Characteristics, Management Practices, And In-hospital Outcomes Among Trauma Patients With Venous Thromboembolism; Background: We aimed to assess the clinical characteristics, management practices, and inhospital outcomes of venous thromboembolism (VTE) among trauma patients. Methods: A retrospective analysis of all trauma patients with documented venous thromboembolic events in a level 1 trauma center was conducted. Patients were categorized into two groups based on the primary initial presentation postinjury (deep-vein thrombosis [DVT] or pulmonary embolism [PE]). Results: Across the study period, a total of 662 patients were confirmed to have DVT and 258 patients were diagnosed with acute PE. Among them, 84 patients were identified to have trauma-associated VTE; 56 (8.5%) had DVT and 28 (10.9%) had PE. Two patients who initially presented with DVT developed PE on follow-up. There were 38 females and 46 males with a mean age of 46 +/- 18 years. Abnormal coagulation profile was reported as 7 protein C deficiencies, 5 protein S deficiencies, 6 homocystinemia, 4 antithrombin III deficiency, 4 lupus anticoagulant, and 2 Factor V Leiden. Age, sex, obesity, D-dimer level, and treatment (except for heparin) were comparable between the two groups; whereas protein S deficiency, prior history of PE, bedridden status, congestive heart failure, and history of recent surgery, were more evident in the PE group. The incidence of postthrombotic syndrome was significantly higher in the DVT group. Overall mortality rate was 8.3% (DVT; 8.9% vs. PE; 7.1%, respectively = 0.78). Conclusion: Coagulation profile plays an important role in posttraumatic thromboembolic disease. A thorough assessment for features of thromboembolic disorders is warranted in polytrauma patients to avoid missing this potentially life-threatening diagnosis. Larger studies are needed for better understanding and management of VTE in trauma., impact, trauma, frequency, risk-factors, prevention, d-dimer, deep-vein thrombosis, japanese patients, manifestation, Outcomes, pulmonary-embolism, risk factors, utility, venous thromboembolism, The publisher's version of record is availible at https://doi.org/10.4103/JETS.JETS_83_19

: Complete Blood Count Parameters Outperform Putative Inflammatory Markers Predicting COVID-19 Mortality; Introduction SARS-CoV-2 evoked immunodysregulation drives inflammation, morbidity, and mortality across COVID-19 presentation spectrum. We sought to identify baseline cell counts and proportions reported with a complete blood count (CBC) that contribute independent information to a model predicting mortality in hospitalized patients with laboratory confirmed SARS-CoV-2 infection, in comparison with inflammatory markers such as CRP, LDH and Ferritin. Methods Under IRB exemption, electronic medical records underwent extraction of demographics, anthropometrics, laboratory test and ICD-10-CM-based Elixhauser comorbidity categories. Univariate logistic regression was used to identify CBC parameters and attendant ratios associated (p<.05) with hospital mortality. Associated parameters underwent Bootstrap Forest (BF) to evaluate aggregated synergies and retain parameters that optimized R2 representing multivariate prediction accuracy and explained variance proportion (EV%) in mortality provided by each parameter. Further BF analysis was used to examine relative magnitude of EV% versus putative COVID-19 inflammatory markers. Longitudinally measured CBC variables included in final BF model were summarized in 24h intervals then pooled after 120h post-admission. Results were averaged when a patient underwent multiple assays within an interval. A two-way ANOVA was employed to compare survival vs. non-survival pathways. Results Among patients consecutively discharged between March 14, 2020 through May 31, 2021, 208 (10 %) of 2153 died. CBC parameters and ratios identified as independently associated with hospital mortality included WBC, lymphocytes, band neutrophils, segmented neutrophils, monocytes, RDW-CV, AMC/ALC and APC/ALC. Results of a BF determined that CBC parameters had an R2 of 0.65 in comparison with Inflammatory markers which had an R2 of 0.52 thus leading to the conclusion that CBC parameters are better predicting mortality in comparison with inflammatory markers. However, integrating CBC parameters with inflammatory markers the R2 was 0.70, further amplifying EV% of mortality. Conclusion Machine learning approaches identified several CBC parameters measured at presentation that when modeled with putative COVID-19 inflammatory markers, enhanced early prediction of hospital mortality. CBC parameters are usually more often measured compared to other inflammatory markers. These represent COVID-19 severity and serve as an easily obtainable source of information to determine which patients may require a higher level of care before clinical symptoms follow. We recommend that CBC parameters, especially band neutrophils, APC/ALC ratio and AMC/ALC ratio be considered for baseline risk stratification of COVID-19 severity, as these trends are sustained at least 5-days after hospitalization., SARS-CoV-2, complete blood count, mortality

: Department of Biomedical Sciences

: Department of Clinical Sciences

: Department of Family Medicine and Rural Health

: Department of Geriatrics

: Disparities In Secure Messaging Uptake Between Patients And Physicians; Background: Emails securely exchanged between patients and clinicians offer the promise of improved access to care and indirectly improved health outcomes. Yet research to date is mixed on who-among both patients and clinicians-is using secure messaging. Objective: Using data from two large nationally representative cross-sectional surveys, this study aimed to compare the prevalence of secure messaging use among patients and their access to the functionality through their physicians, and to explore the clinical practice and physician characteristics and patient sociodemographic characteristics associated with the use of secure messaging. Methods: We conducted regression analyses to identity statistical associations between self-reported secure messaging use and access, and the patient, practice, and physician characteristics from the National Health Interview Survey (NHIS) and the National Ambulatory Medical Care Survey (NAMCS). The NHIS data collected between 2013 and 2018, with approximately 150,000 adult individuals, were used to evaluate patient characteristics associated with email communication with clinicians. The NAMCS data included 7340 physicians who reported on secure messaging use between 2013 and 2016 and provided context on physician specialty, use of certified health information technology (IT), and practice size and ownership associated with secure messaging access and use. Results: By 2016, two-thirds of ambulatory care visits were conducted by a physician who reported using secure messaging, up from 40.70% in 2013. The percentage of US residents who reported sending an email to their clinician, however, only increased from 7.22% to 16.67% between 2013 and 2018. We observed a strong positive association between certified health IT use and secure messaging use (odds ratio [OR] 11.46, 95% CI 7.55-17.39). Individuals who were black, had lower levels of education, had Medicaid or other public payer insurance, or those who were uninsured had reduced odds for using email to communicate with clinicians. No differences were observed in secure messaging use based on physician specialty, but significant differences were observed by practice size (OR 0.46, 95% CI 0.35-0.60 in solo practices vs nonsolo practices) and practice ownership (P<.001 for the different categories). Conclusions: This study is the first to use two large nationally representative surveys to produce longitudinal estimates on the access and use of patient-clinician email communication in the United States. The survey findings complement each other: one provides the patient perspective of their use and the other indicates potential patient access to secure messaging based on the use of the functionality by the physicians providing treatment. This study provides nationally representative data on the characteristics of patients and physicians who have access to and are using secure messaging. This information can be used to target interventions to promote adoption and use of secure messaging., quality, providers, care, growth, access, e-mail communication, electronic health records, electronic mail, health communication, The publisher's version of record is availible at https://doi.org/10.2196/12611

: Educational Case; The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see .(1), disease, acid-fast bacilli, diagnostic medicine, Kinyoun stain, Lowenstein-Jensen media, microbiology, mycobacteria, mycobacteriology, pathology competencies, tuberculosis, The publisher's version of record is availible at https://doi.org/10.1177/2374289520901827

: Hemogram Derived Clinical Traits Evinced Differential Contribution to Explained Variance of Mortality Risk Model at Index Hospitalization for SARS-COV-2 infection Across Wuhan/D614G, Delta, Omicron and Omicron ba.x Variants; Introduction SARS-CoV-2 infection promulgates an immune dysregulation that drives an inflammatory cascade therefore inducing morbidity and mortality across the COVID-19 presentation spectrum. Hemogram derived traits associated with COVID-19 severity have been reported but their relative impact across SARS-CoV-2 variants is unclear. We employed sequential machine learning approaches to identify significantly contributing traits with attendant portion of explained variance (EV%) in hospital mortality risk models across predominant SARS-CoV-2 variants. Methods Our retrospective design, analyses and interpretations followed constructs detailed in the Strengthening the Reporting of Observational Studies in Epidemiology reporting guideline. Adult patients with laboratory confirmed COVID-19 who underwent index hospitalization during Wuhan/D614G (March 14, 2020- June 18, 2021), Delta (June 19, 2021- December 18, 2021), Omicron (December 19-March 30, 2022) or Omicron BA.x (March 31, 2022 – April 14, 2023) variant waves at an 820-bed academic public health trust hospital in Florida were studied. Demographics, laboratory results (within 24h of presentation), ICD-10-CM-based comorbidity, COVID-19 directed treatment and administrative data were extracted from electronic medical records under IRB exemption. Generalized regression with adaptive LASSO identified hemogram-derived traits significantly associated with mortality in at least one of the variants while controlling for presentation vital signs, age, sex, extant comorbidities and ultimate COVID-19 directed treatment. Boosted Tree modeling computed within-variant proportion contributed by each trait to model’s accuracy (R2) representing EV% of mortality risk. Traits contributing to one or more variants for at least 1% portion of EV were retained in model. A Bonferroni corrected two-tailed p < .0125 was considered significant. Results We included 6490 consecutively discharge patients distributed across Wuhan/D614G (n=2249), Delta (n=1196), Omicron (n=953) and Omicron BA.x (n=2092) variants with respective mortality of 9.3%, 13.0%, 4.4%, and 2.4% (p< .0001). Obesity was related with higher mortality. Potent synergy can be generated with biomarkers ratios, as seen with Segmented neutrophil/monocyte ratio (SMR) and lymphocyte/monocyte ratio (LMR), compared to studying these variables individually. Platelets counts were associated with mortality in Delta, Wuhan/D614G and Omicron variants. Decrease of eosinophils was seen in Wuhan/D614G and Delta. Conclusion Sequential machine-learning approaches identified differential expression intensity across SARS-CoV-2 variants in presentation hemogram-derived traits associated with hospital mortality risk modeling at index infection. These findings suggest that COVID-19 presentation risk and level of care assessment tools employing hemogram-derived traits may not generalize across pandemic variants. Studies have shown that platelet activation generates a cascade with more thromboxane A2, platelet thrombofactor A, and beta-thromboglobulin which increases prothrombotic states. The absence of eosinophils was seen in Wuhan/D614G and Delta, the cause of which cannot be ascertained. One of the theories is that the inflammation caused by SARS-CoV-2 infection releases certain cytokines that induce eosinophil apoptosis. Lymphopenia seen throughout variants contributes to an increase in LMR. One presumption is that the SARS-CoV-2 affects T-Lymphocytes through ACE-2 receptor and CD117 spike proteins. Overall, our study brings to attention how hemogram-derived traits express differently across SARS-CoV-2 variants, which could guide the stratification of COVID-19 severity and assist in the care of patients before decompensation is noticed., Hemogram, SARS-CoV-2 Infection, Variants

: In-Hospital Outcomes of Autologous Stem Cell Transplantation in Multiple Myeloma Patients with Versus Without Heart Failure; Background: Autologous stem cell transplantation (ASCT) in patients with multiple myeloma (MM) is known to improve progression-free survival. However, the outcomes in patients with heart failure (HF) are uncertain. This study aims to compare hospital outcomes in patients with MM undergoing ASCT with and without HF. Methods: The National Inpatient Sample database was used to identify patients with MM undergoing ASCT during hospitalizations between 2016 and 2020. Under IRB exemption, data was extracted using ICD-10 codes. Data were stratified between patient with and without HF. A multivariate regression model was used to estimate the association of HF with ASCT in hospital outcomes, adjusting for statistically significant comorbidities. Results: A total of 30,375 hospitalizations with a diagnosis of MM undergoing ASCT were included, of which 1,535 had HF. On multivariant analysis compared to hospitalization without HF, those with HF had significantly higher risk of in-hospital mortality (adjusted odds ratio [aOR]: 2.20, 95% confidence interval [CI]: 1.49-3.24), graft-versus-host disease (GvHD) (aOR: 4.02, 95% [CI]: 2.48-6.52), transplant complications (aOR: 2.03, 95% [CI]: 1.62-2.56), sepsis (aOR: 2.279, 95% [CI]: 1.95- 2.65), septic shock (aOR: 3.49, 95% [CI]: 2.71-4.48), cardiogenic shock (aOR: 5.33, 95% [CI]: 2.61- 10.9), cardiac arrest (aOR: 3.78, 95% [CI]: 2.24- 6.35) and ventricular arrythmia (aOR: 2.81, 95% [CI]: 2.08- 3.78). All p-values were < 0.001. Additionally, patients with HF had a longer average length of stay (20.48 vs 16.38 days, p < 0.001) and a higher total cost of hospital stay ($245,831 vs $198,732, p < 0.001) compared to those without HF. Conclusions: Our findings demonstrated that patients with multiple myeloma undergoing autologous stem cell transplantation, while also having coexisting heart failure (HF), experienced worse outcomes compared to patients without HF. These patients had a higher risk of transplant complications, GvHD, sepsis, septic shock, cardiogenic shock, cardiac arrest, ventricular arrhythmias and mortality. Additionally, these patients experienced a longer hospital stay with higher healthcare costs. Further interventions and research are warranted to improve outcomes in this group of patients., Autologous stem cell transplantation, multiple myeloma, heart failure

: Indusem Position Paper On The Emerging Electronic Waste Management Emergency; Electronic waste or e-waste is a serious and concerning issue globally. Exponential increase in the production of these instrument have created a man-made problem of e-waste; United Nations has called it as "tsunami of e-waste." Informal management and unsafe disposals have compounded the problem further. The hazardous chemicals, metals, and organic pollutants released from e-waste can lead to serious health consequences such as organ damage, genetic defects, neuropsychiatric illness, and cancer. Problem of e-waste is colossal and should be seen as major public health emergency. In India, use of electronic instrument has increased considerably with less focus on formal waste management and safe disposal. This has created a major health hazard. International health agencies, Indian Council of Medical Research, e-waste regulating bodies, academic institutes, and various government and non-government organizations should join hands together to effectively manage the problems of e-waste. Swacch Bharat Abhiyan started by the honorable Prime Minster should consider e-waste as the top most priority in terms of its safe management and disposal., health, risk, metals, soil, lead, Electronic waste, health hazard, recycling, recycling area, research, waste management, The publisher's version of record is availible at https://doi.org/10.4103/JETS.JETS_139_19

: Internal Medicine Residency Program

: Maguire Medical Library

: PLAID

: Program in Neuroscience

: Red Cell Distribution Width and Putative Severity Markers as Predictors of Short-Term Critical Illness in Hospitalized Cancer Patients; Background An accurate risk stratification tool to predict short-term mortality in hospitalized cancer patients would benefit medical decision making in cancer patients. Red cell distribution width (RDW) has been reported as a predictor of mortality but application to cancer is uncertain. We evaluated whether RDW in cancer patients, independently or in combination with other putative severity markers, obtained within 24h of hospitalization, could predict critical illness defined with a composite outcome (ICU visit, discharge to hospice, or death within 30d). Methods Under IRB exemption, demographic and laboratory data was extracted from electronic medical records of ICD-10 identified cancer patients presenting between January 2020 - June 2023. Sequenced univariate regression and machine learning algorithms evaluated associations and portion of explained variance between composite outcome vs. RDW and peer reviewed candidate biomarkers accounting for covariates. Youden’s index testing identified RDW cut-points. Continuous data summarized as median and compared using Kruskal Wallis test. Discrete data summarized as proportions was compared with chi-square test. Significance was accepted at p<0.05. Results Among 8,771 patients, 2131 (24%) and 6640 (76%) did versus did not experience composite outcome. Similar (p >0.05) intergroup distribution occurred between males (57%) and females (43%) aged 74 [66, 81] years including Whites (92%), Blacks (4%) and other races (4%). RDW levels were higher in patients within the composite group. Cut-points for composite risk respectively for RDW-SD and RDW-CD was 50.3 fL and 14.8%. Further stratification performed by cancer sites revealed that other putative severity markers in combination with RDW also contributed to the risk model. The RDW-CV/albumin ratio demonstrated the most explained variance in composite risk across all cancer sites. Conclusion Our preliminary findings quantitively demonstrated that RDW was independently or in combination with other putative severity markers, associated with short-term cancer progression to composite outcome. The underlying oxidative stress and hypoalbuminemia induced by cancer cachexia can explain the contribution of RDW-CV/albumin ratio to the explained variance in composite risk. Therefore, these markers can be employed to develop risk stratification tools for short- term likelihood in cancer patients experiencing intensive care, hospice discharge, or hospital mortality., Red cell distribution width, short-term mortality, oncology

: Safer Roads To School; Any and all advances made by medical science cannot solve the problem of road traffic injuries (RTIs) in school-going children, especially if the only concerned people are those of the medical fraternity. Children are a vulnerable part of the traveling population and thus have been persistent due to the callous nature of the citizens and policy makers toward road safety and injury prevention. In our multicultural and multilingual country, there is a need for multistakeholder initiative with a countrywide presence if we are to stem the rise of mortality and morbidity due to these accidents. The first question we need to ask is how to prevent road traffic accidents and improve the condition of our roads. Pediatric RTIs are eternal problem of industrial revolution with complications and effects that may affect individual and society with increase in the number of motorized communications. Dedicated capacity building is urgently need who should be able to provide the necessary care to the injured children at the road crash spot as well as should be informed where to take the injured child and whom to contact in the dedicated injury care center while transporting the victims of situations., adolescents, interventions, young-children, trauma, epidemiology, trends, biomechanics, brain-injury, cervical-spine, Pediatric, pediatric head-injury, pediatric trauma, road safety, road traffic accidents, school-aged children, traumatic brain injury, The publisher's version of record is availible at https://doi.org/10.4103/JETS.JETS_71_19

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