Parkland Health & Hospital System

Introduction: Social determinants of health have been found to be independent risk factors for developing intensive care unit (ICU) delirium. Previous data have shown an association between language discordance and increased restraint use in adults receiving mechanical ventilation. However, the association between language discordance and delirium diagnosis has not been previously evaluated. Methods: Primary data sources were Medical Information Mart for Intensive Care IV (MIMIC-IV) and the Korean Medical Information Mart (K-MIMIC). Adult patients admitted to the ICU for ≥48 hours were included. Patients who received neuromuscular blockade were excluded. Delirium was defined as ≥1 positive CAM-ICU assessment. Language discordance (LD) was defined as a non-English preferred language in the MIMIC-IV dataset. LD patients were 1:1 matched to language concordant (LC) patients using nearest-neighbor matching without replacement. A logistic regression model was created with delirium as the dependent variable and LD as the exposure. Covariates included patient age group, vasopressor use, preexisting substance use disorder or dementia, and ICU length of stay (LOS). A secondary linear regression analysis was performed with ICU LOS as the outcome. Results: Of the 47,048 patients from MIMIC-IV who met inclusion criteria, 42,223 were LC and 4,825 were LD. While LD was negatively associated with delirium diagnosis (OR 0.86 [95% CI: 0.79, 0.94]), LD patients were more likely to have “unable to assess” (UTA) CAM-ICU assessments (OR 3.96 [95% CI: 3.57, 4.40]). Both LD (10.0 hours [95% CI: 4.9, 15.1]) and delirium (71.8 hours [95% CI: 66.5, 77.2]) were associated with increased ICU LOS. Of note, a much lower incidence of delirium was found in the K-MIMIC dataset (3.4%) as compared to the MIMIC-IV dataset (37.2%). Conclusions: While LD is negatively associated with delirium diagnosis, there is a strong positive association with UTA CAM-ICU assessments. Increased UTA CAM-ICU assessments among LD patients may result in systematic under-diagnosis of ICU delirium. Both delirium and LD are associated with increased ICU LOS. UTA CAM-ICU documentation is common and its effect on the empiric treatment of delirium remains unknown, and further investigation is required.

Abstract Background The significance of Candida species and other fungi isolated in diabetic foot infections (DFI) is unclear. Do these isolates require treatment? Antifungal treatment carries additional cost and risk of adverse events. In this study, we compared outcomes among patients with DFI that were treated vs. not treated for fungi isolated from surgical specimens. Methods We conducted a retrospective review of adults undergoing surgery for DFI with surgical cultures positive for fungi from Oct 1, 2019 to Sept 30, 2022, at a teaching hospital in Dallas, Texas. Patient outcomes were assessed up until last recorded visit or 12 months post-surgery. Descriptive statistics were used to describe the study cohort using medians and interquartile range (IQR) for continuous variables and percentages for categorical variables. To compare outcomes among treated versus untreated patients, Fisher’s Exact Test was used with α=0.05 (R v4.4.1). Results Forty-seven limbs from 46 patients had positive fungal cultures. Median age was 59 years, 68 % male, 62% white, 30% Hispanic, median HgA1c was 7.8%, with 52% having excisional debridements, 19% toe amputation, 13 % ray amputation, 15% transmetatarsal amputation and 2% above or below-knee amputation. Sixty percent of all cases had non-healing wounds. Yeast grew in 70% of specimens, with C. parapsilosis being most common (36%), followed by C. albicans (13%). Mold grew in 32% of specimens including dermatophytes in 19% of specimens. Most patients (68%) were not treated for fungal infection. When comparing patients treated vs. untreated for positive fungal cultures, there were no statistically significant differences in wound healing (53% vs 62%), subsequent amputation (27% vs 28%,) or all-cause mortality (47% vs 25%). Conclusion Our findings did not demonstrate significant differences in outcomes among patients that were or were not treated for positive fungal cultures in patients undergoing surgery for DFI. Compared to prior DFI studies, patient mortality rates were similar although rates of non-healing wounds were higher. While outcomes in DFI are dependent on multiple factors, further research is needed to determine the need/added value of treatment for fungal organisms isolated from surgical specimens in DFI. Disclosures All Authors: No reported disclosures

BackgroundIn non-small cell lung cancer (NSCLC), programmed death-ligand 1 (PD-L1) expression has moderate ability to predict immune checkpoint inhibitor (ICI) benefit. In clinical practice, PD-L1, a cell surface protein, cannot be characterized in currently available blood-based tests such as circulating tumor DNA assays. To understand the biologic effects of PD-L1 more fully and evaluate whether blood-based tests could provide insight into its expression, we determined the association between PD-L1 expression and systemic immune parameters.MethodsWe collected pre- and post-treatment (6-week) peripheral blood samples in patients with NSCLC treated with ICI. Using multiplex panels and cytometry by time of flight (CyTOF), we analyzed specimens for baseline and post-treatment changes in cytokines, autoantibodies, and immune cell populations. We determined the association between case characteristics, immune parameters, and tumor PD-L1 expression (categorized as <1%, 1–49%, and ≥50%) using Chi-square, one-way analysis of variance (ANOVA), and Kruskal-Wallis tests, accounting for multiple comparisons.ResultsA total of 119 patients were included in the analysis, of whom 41 (34%) had PD-L1 expression <1%; 44 (37%), 1–49%; and 34 (29%), ≥50%. PD-L1 expression was not associated with any demographic, tumor, or treatment characteristics. Among 39 cytokines evaluated, baseline levels of macrophage migration inhibitory factor (MIF) were significantly greater in high PD-L1 positive cases. Among 124 autoantibodies included in the analysis, three (anti-aggrecan, -proteoglycan, and -nucleosome) demonstrated significantly greater post-ICI treatment increases in cases with higher PD-L1 expression. In PD-L1 positive cases, baseline abundance of natural killer T (NKT) cells (P=0.001) and activated monocytes (P=0.04) were significantly lower, while post-treatment increases in mature natural killer (NK) cells were significantly greater (P=0.006).ConclusionsNSCLC PD-L1 expression is associated with few systemic immune parameters, suggesting that effects on anti-tumor immunity may occur predominantly in the tumor microenvironment and that blood-based assays are unlikely to provide meaningful surrogates of this biomarker.

Sickle cell disease (SCD) is associated with vaso-occlusive episodes (VOEs) that often require inpatient care. Parenteral opioids are recommended as first-line VOE treatment in hospitalized patients. The Current Opioid Misuse Measure (COMM) survey was used to screen for aberrant opioid use in SCD patients hospitalized for VOE. Goals were to estimate the proportion of positive screens and evaluate associations with length of stay (LOS), electronic health record (EHR) data, and Prescription Drug Monitoring Program (PDMP) assessments. SCD patients hospitalized for VOE were approached to complete COMM surveys. Descriptive statistics and multivariate modeling were used to evaluate whether COMM results were associated with LOS or secondary variables. A total of 111 patients were approached and 89 completed surveys. Approximately 6 in 10 (57.3%) respondents screened positive for aberrant opioid use using a sensitive COMM threshold (≥9). A more specific threshold (≥13) identified about 3 in 10 (31.7%) of respondents. Positive COMM screens were more common among younger patients and those with a higher EHR risk index (Epic general risk score). COMM score was positively correlated with LOS (Spearman r =0.25, P =0.025), although this association was nonsignificant in survival models adjusted for sex and age ( P ≥0.081). A high proportion of adults admitted for VOE screened positively using the COMM survey, which is a sensitive indicator of opioid misuse among outpatients. Our findings demonstrate feasibility of inpatient screening using the COMM survey and support further investigation of this tool for SCD patients hospitalized with VOE.

ABSTRACTUpper tract urothelial carcinoma (UTUC) is an uncommon and aggressive malignancy that often presents as an invasive disease. After receiving systemic therapy, stereotactic body radiation therapy (SBRT) offers a non‐surgical option for consolidative local tumor control by delivering radiation doses in limited fractions. While SBRT is generally well tolerated in the treatment of UTUC, there is a small but serious risk of radiation‐associated complications. We present a case of a 67‐year‐old male with metastatic UTUC of the renal pelvis treated with chemotherapy and immunotherapy. Due to persistent disease at the primary site, he underwent consolidative SBRT using a PULSAR (Personalized Ultra‐fractionated Stereotactic Adaptive Radiotherapy) approach to his left kidney mass. Weeks later, he developed a renocolic fistula that was complicated by sepsis. Despite a diverting colostomy and antibiotics, he re‐presented with hemorrhagic shock due to an aortocolonic fistula that required emergent endovascular aortic repair (EVAR). This case illustrates a rare but serious complication of consolidative SBRT in a patient with extensive retroperitoneal malignancy. Multidisciplinary planning and close surveillance are critical to ensuring the safe integration of SBRT in the management of metastatic UTUC.

AimsIn the randomized DAPA‐MI clinical trial, 10 mg of dapagliflozin once daily improved cardiometabolic outcomes versus placebo after acute myocardial infarction (MI) in patients without established diabetes or heart failure (HF). We assessed associations between baseline left ventricular ejection fraction (LVEF) and cardiometabolic outcomes in DAPA‐MI.MethodsThe primary outcome, assessed using the win ratio method, was the hierarchical composite of death, hospitalization for HF, non‐fatal MI, atrial fibrillation/flutter, Type 2 diabetes, New York Heart Association classification at last visit and body weight decrease of ≥5% from baseline to last visit. For the present analysis, patients were categorized using LVEF at randomization (<50% or ≥50%).ResultsOf the DAPA‐MI participants with available LVEF data who received ≥1 dose of study drug (n = 3751), 2913 (77.7%) had LVEF <50% and 838 (22.3%) had LVEF ≥50%. The primary hierarchical composite outcome resulted in a win ratio favouring dapagliflozin of 1.38 (95% CI: 1.21, 1.57; P < 0.001) in patients with LVEF <50% and 1.32 (1.00, 1.73; P = 0.048) in patients with LVEF ≥ 50% (P interaction = 0.76). In a sensitivity analysis excluding patients with LVEF <30%, the primary hierarchical composite outcome resulted in a win ratio favouring dapagliflozin of 1.40 (95% CI: 1.22, 1.61; P < 0.001). There were no significant interactions between baseline LVEF and any secondary outcomes.ConclusionsRegardless of baseline LVEF, dapagliflozin resulted in significant cardiometabolic benefits versus placebo, although there was no impact on the composite of cardiovascular death or hospitalization for HF.

PurposeDecreased access to care and social drivers of health have been implicated in COVID-19 disparities. The objective of this study was to test the association between county-funded charity coverage (CFCC) and mortality among uninsured patients hospitalized with COVID-19 in a highly uninsured county.MethodsThis retrospective cohort study compared electronic health record (EHR) data among uninsured patients hospitalized with COVID-19 in a high-volume safety-net health system in Dallas County, Texas between June 2020 and December 2021. Uninsured patients included CFCC recipients and self-pay patients. We compared mortality over 180 days of follow-up using Cox proportional hazards models, adjusting for gender, age, race/ethnicity, and co-morbidities. Additional outcomes included 90-day mortality, need for mechanical ventilation, and intubation within 24 hours of presentation.ResultsAmong 2,047 patients, 47.0% received CFCC and 53.0% were self-pay. Overall, CFCC patients were older, more likely Hispanic, and had more diagnosed co-morbidities. CFCC patients had decreased adjusted mortality compared to self-pay (aHR 0.61, 95% CI [0.45 to 0.82], p < 0.01), with an absolute risk reduction of 3.3% and a number needed to treat (NNT) with CFCC of 30.4 (95% CI 21.4–66.6). CFCC was associated with lower 90-day mortality compared to self-pay (OR = 0.64, 95% CI [0.45–0.92], p = 0.01), despite similar need for ventilation. Intubation within 24 hours of presentation was lower for CFCC compared to self-pay (OR = 0.46, 95% CI [0.22–0.93], p = 0.03).ConclusionsCFCC was associated with decreased mortality among the uninsured hospitalized with COVID-19. The NNT for CFCC to prevent 1 death among uninsured patients was similar to that for standard medications to treat COVID-19. These findings support expanding coverage to improve COVID-19 outcomes.