The Predictive Validity of Functional Outcome Measures With Discharge Destination for Hospitalized Medical Patients

OBJECTIVE: To investigate the predictive validity for discharge to home or facility of 4 functional mobility outcome measures. DESIGN: Retrospective, observational study. SETTING: Urban, academic hospital in the United States. PARTICIPANTS: Adult patients (N=3999) admitted to medical units between June 1, 2019, and February 29, 2020, with 2 or more recorded scores on each of 4 tools: Activity Measure for Post-Acute Care (AM-PAC) 6-Clicks Basic Mobility and Daily Activity, Henry Ford Mobility Level, and The Johns Hopkins Highest Level of Mobility. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mobility scores and discharge destination. RESULTS: For the 3999 subjects, 51.4% went home at discharge and had higher mean scores on each measure than those not returning home. Both early (I) and later (II) time point for each measure had positive predictability for discharge home. AM-PAC 6-Clicks had the highest confidence intervals for early and later recorded scores. The c-statistic value for Basic Mobility I (cut point=16) was 0.74 and for II (cut point=18) was, 0.79. The value for Daily Activity I (cut point=18) was 0.75 and for Daily Activity II (cut point=18) was 0.80). The Johns Hopkins Highest Level of Mobility and Henry Ford Mobility Level measures were less discriminative at initial score (c-statistic 0.704 and 0.665, respectively) and final score (c-statistic 0.74 and 0.75, respectively). CONCLUSIONS: Functional outcome measures have good predictive validity for discharge destination. The AM-PAC Basic mobility score appears to have a slightly higher confidence interval than the other tools in this study design

Laboratory monitoring and antiviral treatment for chronic hepatitis B among routine care patients in the United States

We investigated factors associated with rates of recommended monitoring of chronic hepatitis B (HBV) patients for viral DNA and alanine aminotransferase (ALT), and initiation of antiviral treatment among eligible patients, in a US cohort of patients under routine care. Patients were categorised by treatment indication: definite, equivocal or ineligible. Baseline covariates included demographics, clinical characteristics and specialist care status. \u27Recommended monitoring\u27 was defined ≥1 ALT or HBV DNA test per year. Logit models, univariate then multivariable, were used to evaluate factors associated with monitoring and treatment. Among 3,830 patients, treatment was received by 67.5% (788/1168 patients) in the \u27definite\u27 category, and 34.1% (208/610 patients) in the \u27equivocal\u27 category, of whom 109 moved up to \u27definite\u27 status at some point during follow-up. Sex, age and specialist care were independently associated with receipt of treatment in \u27definite\u27 patients. Routine monitoring rates were high prior to treatment in \u27definite/ treated\u27 patients (ALT: 77%; DNA: 85%) but declined afterwards (ALT 63%; DNA 36%). Rates of monitoring were lower in \u27definite/ untreated\u27 patients (ALT: 48%; DNA: 32%). Among \u27equivocal/ treated\u27 patients, lower age and comorbidity scores were associated with receipt of treatment; ALT monitoring rates were similar before and after treatment initiation (41% and 46%, respectively), while rates of DNA monitoring declined (55% and 29%). Monitoring among \u27treatment ineligible\u27 patients was similar to those in the \u27equivocal\u27 and untreated \u27definite\u27 groups. A large proportion of US HBV patients under routine care did not receive recommended annual laboratory monitoring, especially after initiation of antiviral treatment, and nearly one-third of patients with \u27definite\u27 indications for antiviral therapy remained untreated

Availability of PEth testing is associated with reduced eligibility for liver transplant among patients with alcohol-related liver disease

BACKGROUND: Serum phosphatidylethanol (PEth) is a highly sensitive test to detect alcohol use. We evaluated whether the availability of PEth testing impacted rates of liver transplant evaluation terminations and delistings. METHODS: Medical record data were collected for patients who initiated transplant evaluation due to alcohol-related liver disease in the pre-PEth (2017) or PEth (2019) eras. Inverse probability weighting (IPW) was used to balance baseline patient characteristics. Outcomes included termination of evaluation or delisting due to alcohol use; patients were censored at receipt of transplant; death was considered a competing risk. The Fine-Gray method was performed to determine whether PEth testing affected risk of evaluation termination/ delisting due to alcohol use. RESULTS: Three hundred and seventy-five patients with alcohol-related indications for transplant (157 in 2017; 210 in 2019) were included. The final IPW-adjusted model for the composite outcome of terminations/delisting due to alcohol use retained two significant variables (P \u3c .05): PEth era and BMI category. Patients evaluated during the PEth era were almost three times more likely to experience an alcohol-related termination/delisting than those in the pre-PEth era (sHR = 2.86; 95%CI 1.67-4.97). CONCLUSION: We found that availability of PEth testing at our institution was associated with a higher rate of exclusion of patients from eligibility for liver transplant. Use of PEth testing has significant potential to inform decisions regarding transplant candidacy for patients with alcohol-related liver disease

Social distancing during the COVID-19 pandemic: quantifying the practice in Michigan - a hotspot state early in the pandemic - using a volunteer-based online survey

BACKGROUND: Public Health policies related to social distancing efforts during the COVID-19 pandemic helped slow the infection rate. However, individual-level factors associated with social distancing are largely unknown. We sought to examine social distancing during the COVID-19 pandemic in Michigan, an infection hotspot state in the United States early in the pandemic. METHODS: Two surveys were distributed to Michigan residents via email lists and social media following COVID-19 related state mandates in March; 45,691 adults responded to the first survey and 8512 to the second. Staying home ≥ 3 out of 5 previous days defined having more social distancing. Logistic regression models were used to examine potential factors associated with more social distancing. RESULTS: Most respondents were women (86% in Survey 1, 87% in Survey 2). In Survey 1, 63% reported more social distancing, increasing to 78% in Survey 2. Female sex and having someone (or self) sick in the home were consistently associated with higher social distancing, while increasing age was positively associated in Survey 1 but negatively associated in Survey 2. Most respondents felt social distancing policies were important (88% in Survey 1; 91% in Survey 2). CONCLUSIONS: Michiganders responding to the surveys were both practicing and supportive of social distancing. State-level executive orders positively impacted behaviors early in the COVID-19 pandemic in Michigan. Additional supports are needed to help vulnerable populations practice social distancing, including older individuals

Trends in Cirrhosis and Mortality by Age, Sex, Race, and Antiviral Treatment Status Among US Chronic Hepatitis B Patients (2006-2016)

BACKGROUND: Changing US demographics and evolving chronic hepatitis B (CHB) treatments may affect longitudinal trends in CHB-related complications. We studied trends in the prevalence of cirrhosis (past or present) and incidence of all-cause mortality, stratified by patient age, sex, race, and antiviral treatment status, in a sample from US health care systems. METHODS: Joinpoint and Poisson regression (univariate and multivariable) were used to estimate the annual percent change in each outcome from 2006 to 2016. RESULTS: Among 5528 CHB patients, cirrhosis prevalence (including decompensated cirrhosis) rose from 6.7% in 2006 to 13.7% in 2016; overall mortality was unchanged. Overall rates of cirrhosis and mortality were higher among treated patients, but adjusted annual percent changes (aAPC) were significantly lower among treated than untreated patients (cirrhosis: aAPC +2.4% vs. +6.2%, mortality: aAPC -3.9% vs. +4.0%). Likewise, among treated patients, the aAPC for mortality declined -3.9% per year whereas among untreated patients, mortality increased +4.0% per year. CONCLUSIONS: From 2006 to 2016, the prevalence of cirrhosis among CHB patients doubled. Notably, all-cause mortality increased among untreated patients but decreased among treated patients. These results suggest that antiviral treatment attenuates the progression of cirrhosis and the risk of death among patients with CHB

Intraclass Correlations of Measured Magnetic Resonance Imaging Volumes of Laser Interstitial Thermal Therapy-Treated High-Grade Gliomas

BACKGROUND AND OBJECTIVES: Laser interstitial thermal therapy (LITT) is a minimally invasive therapeutic option for the treatment of brain tumors. Previous studies have quantitatively followed the ablated volumes of high-grade gliomas. Reported treatment volumes range from 28% to 100%, with no reported interobserver analysis. Because these volumes are subjectively measured, it is necessary to establish concordance between clinicians. STUDY DESIGN/MATERIALS AND METHODS: Utilizing Brainlab tumor analysis software (Brainlab, Munich, Germany), five physician users traced out tumor volumes slice-by-slice on 10 treated tumors in eight patients. The participants were briefed with specific instructions and a demonstration on how to trace the enhancing borders of the tumor slice-by-slice. Volumes automatically calculated by the Brainlab software included preoperative, intraoperative ablation and postoperative enhancing volumes. Data regarding size, cystic appearance, pathology, previous surgery, and demographics were included. RESULTS: The intraclass correlation coefficient (ICC) for preoperative, intraoperative, and postoperative volumes was 0.92 (95% confidence interval, [CI] 0.81-0.97), 0.90 (0.77-0.96), and 0.89 (0.74-0.96), respectively. The overall ICC was 0.72 (0.50-0.87). ICC comparisons were also made for each pair of readers (neuroradiologist, neuro-oncologist, senior neurosurgery resident, neurosurgery junior resident) which resulted in pretreatment ICC scores of 0.97, 0.91, 0.66, 0.94; intratreatment scores of 0.97, 0.78, 0.90, 0.96; and posttreatment scores of 0.96, 0.81, 0.89, and 0.87. A Bland-Altman plot was also used to assess the differences in volumes. CONCLUSIONS: The ICC gives a composite of the consistency of measurements made by multiple observers measuring the same quantity. The overall ICC of 0.72 means there is good correlation between observers in our study between measured volumes

Intraclass Correlations of Measured Magnetic Resonance Imaging Volumes of Laser Interstitial Thermal Therapy-Treated High-Grade Gliomas

BACKGROUND AND OBJECTIVES: Laser interstitial thermal therapy (LITT) is a minimally invasive therapeutic option for the treatment of brain tumors. Previous studies have quantitatively followed the ablated volumes of high-grade gliomas. Reported treatment volumes range from 28% to 100%, with no reported interobserver analysis. Because these volumes are subjectively measured, it is necessary to establish concordance between clinicians. STUDY DESIGN/MATERIALS AND METHODS: Utilizing Brainlab tumor analysis software (Brainlab, Munich, Germany), five physician users traced out tumor volumes slice-by-slice on 10 treated tumors in eight patients. The participants were briefed with specific instructions and a demonstration on how to trace the enhancing borders of the tumor slice-by-slice. Volumes automatically calculated by the Brainlab software included preoperative, intraoperative ablation and postoperative enhancing volumes. Data regarding size, cystic appearance, pathology, previous surgery, and demographics were included. RESULTS: The intraclass correlation coefficient (ICC) for preoperative, intraoperative, and postoperative volumes was 0.92 (95% confidence interval, [CI] 0.81-0.97), 0.90 (0.77-0.96), and 0.89 (0.74-0.96), respectively. The overall ICC was 0.72 (0.50-0.87). ICC comparisons were also made for each pair of readers (neuroradiologist, neuro-oncologist, senior neurosurgery resident, neurosurgery junior resident) which resulted in pretreatment ICC scores of 0.97, 0.91, 0.66, 0.94; intratreatment scores of 0.97, 0.78, 0.90, 0.96; and posttreatment scores of 0.96, 0.81, 0.89, and 0.87. A Bland-Altman plot was also used to assess the differences in volumes. CONCLUSIONS: The ICC gives a composite of the consistency of measurements made by multiple observers measuring the same quantity. The overall ICC of 0.72 means there is good correlation between observers in our study between measured volumes

Alcohol-related hepatitis admissions increased 50% in the first months of the CoViD-19 pandemic in the US

Early reports suggest that alcohol misuse increased in 2020 due to the CoViD-19 pandemic. Using retrospective data from Henry Ford Health System in Detroit MI-an area that experienced an early and severe CoViD-19 outbreak-to investigate the impact of the pandemic on alcohol-related liver disease (ARLD) in the summer of 2020 compared to the same period in 2016-2019. Both the number of ARLD admissions and the proportion of total admissions represented by ARLD patients increased significantly in 2020 compared to previous years. The number of ARLD admissions as a proportion of all hospitalizations was 50% higher in 2020 than in 2016-2019 (0.31% versus 0.21%; p=0.0013); by September 2020, the number of admissions was 66% higher than previous years. Despite racial and geographic disparities in direct and indirect CoViD-related stressors across the Detroit metropolitan area, the demographic profile of ARLD patients did not change compared to previous years

Alcohol-related hepatitis admissions decline in 2021 after a 2020 surge attributed to the COVID-19 pandemic

OBJECTIVE: We previously investigated the impact of the COVID-19 pandemic on alcohol-related liver disease (ARLD), finding that admissions for alcoholic hepatitis (AH) increased by 50% in the summer of 2020 compared to the same period in 2016-2019. We have now expanded our analysis to consider full years\u27 data and evaluate how rates changed in 2021. We also sought to identify factors associated with ICU admissions, need for dialysis, liver transplant evaluations, and death. METHODS: Using retrospective data, we identified patients admitted to our four Detroit, Michigan area hospitals for acute ARLD for three periods pre-COVID (2016-February 2020), early COVID (June-December 2020), and late COVID (2021). Clustered logistic regression was performed to study rates of AH admissions across the three eras, where the patient was defined as the cluster and the analysis accounted for multiple encounters per cluster. A similar regression approach, univariate followed by multivariable analysis, was also used to study associations between patient characteristics and outcomes during hospitalization for AH. RESULTS: AH-related admissions declined significantly from the early COVID to late COVID eras (OR 0.68, 95% CL 0.52, 0.88), returning to levels similar to that of the pre- COVID period (OR 1.18, 95% CL 0.96, 1.47). In multivariable analysis, baseline MELD score was associated with ICU admission, initiation of dialysis, transplant evaluation, and death while hospitalized for AH. Female patients were at almost twice the risk of death during admission compared to male patients (aOR 1.81, 95% CL 1.1, 2.98). Increasing age was associated with slightly lower odds of transplant (aOR 0.97, 95% CL 0.94, 1) and higher odds of death (aOR 1.03, 95% CL 1.01. 1.06). CONCLUSION: After a spike in AH-related admissions during the first summer of the COVID-19 pandemic, rates declined significantly in 2021, returning to pre-pandemic levels

Inflammatory leukocyte phenotypes correlate with disease progression in idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is characterized by progressive deposition of extracellular matrix, worsening dyspnea, and eventual mortality. Pathogenesis of IPF is poorly understood and the role inflammation and activated leukocytes play in the disease process is controversial. Previous studies demonstrated that activated leukocyte subsets characterize IPF patients. We sought to validate this observation in a well-defined cohort of 35 IPF patients and to correlate the observed leukocyte phenotypes with robust parameters of disease progression. We demonstrate that in univariate and multivariate analyses, increases in the CD14hi, CD16hi subset of monocytes measured at baseline correlated with disease progression, with a threshold value >0.5% of the total peripheral blood mononuclear cells being a significant predictor for worse outcome. In addition, several T cell subsets, including CD25 expressing CD4 cells, and CXCR3 expressing CD4 and CD8 subsets correlated with disease progression when found in increased percentages in the peripheral blood of IPF patients when sampled at baseline. Somewhat surprising in comparison to previous literature, the CD4 T cells did not appear to have lost expression of the co-stimulatory molecule, CD28, but the CD8 T cells did. Taken together, these results are consistent with the presence of an inflammatory process in IPF patients who eventually progress. However, when longitudinal measurements of these same markers were examined, there was significant heterogeneity of expression and these biomarkers did not necessarily remain elevated in IPF patients with progressive disease. We interpret this heterogeneity to suggest that IPF patients experience episodic inflammatory events that once triggered, may lead to disease progression. This longitudinal heterogeneity in biomarker analyses may explain why such markers are not consistently measured in all IPF cohorts