Publications

AIM: Acute decompensated heart failure (ADHF) is the leading cause of cardiovascular hospitalizations in the United States. Detecting B-lines through lung ultrasound (LUS) can enhance clinicians' prognostic and diagnostic capabilities. Artificial intelligence/machine learning (AI/ML)-based automated guidance systems may allow novice users to apply LUS to clinical care. We investigated whether an AI/ML automated LUS congestion score correlates with expert's interpretations of B-line quantification from an external patient dataset.

METHODS AND RESULTS: This was a secondary analysis from the BLUSHED-AHF study which investigated the effect of LUS-guided therapy on patients with ADHF. In BLUSHED-AHF, LUS was performed and B-lines were quantified by ultrasound operators. Two experts then separately quantified the number of B-lines per ultrasound video clip recorded. Here, an AI/ML-based lung congestion score (LCS) was calculated for all LUS clips from BLUSHED-AHF. Spearman correlation was computed between LCS and counts from each of the original three raters. A total of 3858 LUS clips were analysed on 130 patients. The LCS demonstrated good agreement with the two experts' B-line quantification score (r = 0.894, 0.882). Both experts' B-line quantification scores had significantly better agreement with the LCS than they did with the ultrasound operator's score (p < 0.005, p < 0.001).

CONCLUSION: Artificial intelligence/machine learning-based LCS correlated with expert-level B-line quantification. Future studies are needed to determine whether automated tools may assist novice users in LUS interpretation.

INTRODUCTION: Hypertension is often incidentally discovered in the emergency department (ED); these patients may benefit from close follow-up. We developed a module to automatically include discharge instructions for patients with elevated blood pressure (BP) in the ED, aiming to improve 30-day follow-up.

AIM: This study sought to determine if automated discharge instructions for patients with elevated blood pressure in the ED improved 30-day follow-up with a patient's primary care physician (PCP).

METHODS: We developed an automated module with standardized instructions for patients with elevated BP. These were read upon discharge, and e-mailed to the PCP. We analyzed 193 patients during a 1-month interval after implementation, and 207 during 1-month the year prior. The groups were compared using Fisher's exact test.

RESULTS: Thirty-day follow-up was 52.2% pre-implementation and 48.4% post-implementation, with no significant difference noted. For patients without known hypertension, follow-up slightly improved, but not significantly. For hypertensive patients, follow-up rates significantly decreased post-implementation.

CONCLUSIONS: Despite implementation of automated discharge instructions, we found no improvement in 30-day follow-up. Patients without hypertension trended towards improved follow-up, possibly being more attentive to new abnormal BP readings. However, known hypertensive patients followed-up at a lower rate, which was unexpected and requires further investigation.

Background: Since 2017, states, insurers, and pharmacies have placed blanket limits on the duration and quantity of opioid prescriptions. In many states, overlapping duration and daily dose limits yield maximum prescription limits of 150-350 morphine milligram equivalents (MMEs). There is limited knowledge of how these restrictions compare with actual patient opioid consumption; while changes in prescription patterns and opioid misuse rates have been studied, these are, at best, weak proxies for actual pain control consumption. We sought to determine how patients undergoing surgery would be affected by opioid prescribing restrictions using actual patient opioid consumption data. Methods: We constructed a prospective database of post-discharge opioid consumption: patients undergoing surgery at one institution were called after discharge to collect opioid consumption data. Patients whose opioid consumption exceeded 150 and 350 MME were identified. Results: Two thousand nine hundred and seventy-one patients undergoing 54 common surgical procedures were included in our study. Twenty-one percent of patients consumed more than the 150 MME limit. Only 7% of patients consumed above the 350 MME limit. Typical (non-outlier) opioid consumption, defined as less than the 75th percentile of consumption for any given procedure, exceeded the 150 MME and 350 MME limits for 41 and 7% of procedures, respectively. Orthopedic, spinal/neurosurgical, and complex abdominal procedures most commonly exceeded these limits. Conclusions: While most patients undergoing surgery are unaffected by recent blanket prescribing limits, those undergoing a specific subset of procedures are likely to require more opioids than the restrictions permit; providers should be aware that these patients may require a refill to adequately control post-surgical pain. Real consumption data should be used to guide these restrictions and inform future interventions so the risk of worsened pain control (and its troublesome effects on opioid misuse) is minimized. Procedure-specific prescribing limits may be one approach to prevent misuse, while also optimizing post-operative pain control.

BACKGROUND: Post-discharge opioid consumption is a crucial patient-reported outcome informing opioid prescribing guidelines, but its collection is resource-intensive and vulnerable to inaccuracy due to nonresponse bias.

METHODS: We developed a post-discharge text message-to-web survey system for efficient collection of patient-reported pain outcomes. We prospectively recruited surgical patients at Beth Israel Deaconess Medical Center in Boston, Massachusetts from March 2019 through October 2020, sending an SMS link to a secure web survey to quantify opioids consumed after discharge from hospitalization. Patient factors extracted from the electronic health record were tested for nonresponse bias and observable confounding. Following targeted learning-based nonresponse adjustment, procedure-specific opioid consumption quantiles (medians and 75th percentiles) were estimated and compared to a previous telephone-based reference survey.

RESULTS: 6553 patients were included. Opioid consumption was measured in 44% of patients (2868), including 21% (1342) through survey response. Characteristics associated with inability to measure opioid consumption included age, tobacco use, and prescribed opioid dose. Among the 10 most common procedures, median consumption was only 36% of the median prescription size; 64% of prescribed opioids were not consumed. Among those procedures, nonresponse adjustment corrected the median opioid consumption by an average of 37% (IQR: 7, 65%) compared to unadjusted estimates, and corrected the 75th percentile by an average of 5% (IQR: 0, 12%). This brought median estimates for 5/10 procedures closer to telephone survey-based consumption estimates, and 75th percentile estimates for 2/10 procedures closer to telephone survey-based estimates.

CONCLUSIONS: SMS-recruited online surveying can generate reliable opioid consumption estimates after nonresponse adjustment using patient factors recorded in the electronic health record, protecting patients from the risk of inaccurate prescription guidelines.

OBJECTIVE: We compare consensus recommendations for 5 surgical procedures to prospectively collected patient consumption data. To address local variation, we combined data from multiple hospitals across the country.

SUMMARY OF BACKGROUND DATA: One approach to address the opioid epidemic has been to create prescribing consensus reports for common surgical procedures. However, it is unclear how these guidelines compare to patient-reported data from multiple hospital systems.

METHODS: Prospective observational studies of surgery patients were completed between 3/2017 and 12/2018. Data were collected utilizing post-discharge surveys and chart reviews from 5 hospitals (representing 3 hospital systems) in 5 states across the USA. Prescribing recommendations for 5 common surgical procedures identified in 2 recent consensus reports were compared to the prospectively collected aggregated data. Surgeries included: laparoscopic cholecystectomy, open inguinal hernia repair, laparoscopic inguinal hernia repair, partial mastectomy without sentinel lymph node biopsy, and partial mastectomy with sentinel lymph node biopsy.

RESULTS: Eight hundred forty-seven opioid-naïve patients who underwent 1 of the 5 studied procedures reported counts of unused opioid pills after discharge. Forty-one percent did not take any opioid medications, and across all surgeries, the median consumption was 3 5 mg oxycodone pills or less. Generally, consensus reports recommended opioid quantities that were greater than the 75th percentile of consumption, and for 2 procedures, recommendations exceeded the 90th percentile of consumption.

CONCLUSIONS: Although consensus recommendations were an important first step to address opioid prescribing, our data suggests that following these recommendations would result in 47%-56% of pills prescribed remaining unused. Future multi-institutional efforts should be directed toward refining and personalizing prescribing recommendations.

INTRODUCTION: Cannabis' effect on seizure activity is an emerging topic that remains without consensus and merits further investigation. We therefore performed a scoping review to identify the available evidence and knowledge gaps within the existing literature on cannabis product exposures as a potential cause of seizures in humans.

METHODS: A scoping review was conducted in accordance with the PRISMA Extension for Scoping Reviews guidelines. The PubMed and Scopus databases were searched over a 20-year period from the date of the database query (12/21/2020). Inclusion criteria were (1) English language original research articles, (2) inclusion of human subjects, and (3) either investigation of seizures as a part of recreational cannabinoid use OR of exogenous cannabinoids as a cause of seizures.

RESULTS: A total of 3104 unique articles were screened, of which 68 underwent full-text review, and 13 met inclusion/exclusion criteria. Ten of 11 studies evaluating acute cannabis exposures reported a higher seizure incidence than would be expected based on the prevalence of epilepsy in the general and pediatric populations (range 0.7-1.2% and 0.3-0.5% respectively). The remaining two studies demonstrated increased seizure frequency and/or seizure-related hospitalization in recreational cannabis users and those with cannabis use disorder.

CONCLUSIONS: This scoping review demonstrates that a body of literature describing seizures in the setting of cannabis exposure exists, but it has several limitations. Ten identified studies showed a higher than expected incidence of seizures in populations exposed to cannabis products. Based on the Bradford Hill criteria, delta-9 tetrahydrocannabinol (THC) may be the causative xenobiotic for this phenomenon.

INTRODUCTION: Ramped position and apneic oxygenation are strategies to mitigate hypoxemia; however, the benefits of these strategies when utilized together remain unclear. Therefore, we compared first-attempt, postinduction hypoxemia between adult emergency department (ED) endotracheal intubations performed with apneic oxygenation in the ramped versus supine positions.

METHODS: We used the National Emergency Airway Registry (NEAR), a multicenter registry of data on ED intubations from 25 academic and community sites. We included first-attempt intubations with direct (DL) and video (VL) laryngoscopy in subjects ≥ 18 years old with nontrauma indications receiving apneic oxygenation. We examined patient characteristics (e.g., sex, obesity) and key intubation outcomes, including hypoxemia (primary outcome), first-pass success, and other adverse events (e.g., bradycardia). In addition, we examined unadjusted odds ratios (OR) and adjusted ORs (aOR) for key variables and stratified by laryngoscope type.

RESULTS: We included 210 ramped cases and 1,820 supine cases in the DL cohort and 202 ramped and 1,626 supine cases in the VL cohort. Rates of postinduction hypoxemia were similar between supine and ramped position in both the DL cohort (supine 6.5% and ramped 7.6%, aOR [95% CI] = 0.96 [0.55 to 1.67]) and the VL cohort (supine 10.1% and ramped 12.4%, aOR [95% CI] = 0.97 [0.60 to 1.56]). Other outcomes were also similar between groups.

CONCLUSION: Using this large national data set, we did not identify a difference in postinduction hypoxemia between ramped and supine positions in this cohort of ED intubations with apneic oxygenation.

INTRODUCTION: Laryngoscope blade shape may differentially facilitate first-attempt success in patients intubated in non-supine positions in the emergency department (ED). Therefore, we analyzed first-attempt success in ramped and upright positions stratified by hyperangulated or standard geometry video laryngoscopes (VL).

METHODS: We performed a secondary analysis of the National Emergency Airway Registry (NEAR) on ED intubations from January 1, 2016 to December 31, 2018. Our primary outcome was first-attempt success, and secondary outcomes included first-attempt success without adverse events and glottic view. We included all VL intubation attempts in the ramped and upright positions on medical patients >17-years-old. We calculated adjusted odds ratios (aOR) using a multivariable logistic regression mixed-effects model with site as a random effect and blade type, obesity / morbid obesity, training level (i.e., post-graduate year), operator-perceived difficult airway, and presence of an objective difficult airway finding as fixed effects.

RESULTS: Our analysis included 266 attempts with hyperangulated blades and 370 attempts with standard geometry blades in the ramped cohort, and 116 attempts with hyperangulated attempts and 55 attempts with standard geometry blades in the upright cohort. In the ramped cohort, 244 (91.7%) of hyperangulated first attempts were successful, and 341 (92.2%) of standard geometry first attempts were successful (aOR 1.02 [95% confidence interval 0.56, 1.84]). In the upright cohort, 107 (92.2%) of hyperangulated first attempts were successful, and 50 (90.9%) of standard geometry first attempts were successful (aOR 1.04 [0.28, 3.86]). There was no difference across the secondary outcomes, including first-attempt success without adverse events.

CONCLUSION: Hyperangulated and standard geometry VL had similar first-attempt success in ramped and upright position intubations in the ED.

INTRODUCTION: Previous studies suggest improved intubation success using video laryngoscopy (VL) vs direct laryngoscopy (DL), yet recent randomized trials have not shown clear benefit of one method over the other. These studies, however, have generally excluded difficult airways and rapid sequence intubation. In this study we looked to compare first-pass success (FPS) rates between VL and DL in adult emergency department (ED) patients with difficult airways.

METHODS: We conducted a secondary analysis of prospectively collected observational data in the National Emergency Airway Registry (NEAR) (January 2016-December 2018). Variables included demographics, indications, methods, medications, devices, difficult airway characteristics, success, and adverse events. We included adult ED patients intubated with VL or DL who had difficult airways identified by gestalt or anatomic predictors. We stratified VL by hyperangulated (HAVL) vs standard geometry VL (SGVL). The primary outcome was FPS, and the secondary outcome was comparison of adverse event rates between groups. Data analyses included descriptive statistics with cluster-adjusted 95% confidence intervals (CI).

RESULTS: Of 18,123 total intubations, 12,853 had a predicted or identified anatomically difficult airway. The FPS for difficult airways was 89.1% (95% CI 85.9-92.3) with VL and 77.7% (95% CI 75.7-79.7) with DL (P <0.00001). The FPS rates were similar between VL subtypes for all difficult airway characteristics except airways with blood or vomit, where SGVL FPS (87.3%; 95% CI 85.8-88.8) was slightly better than HAVL FPS (82.4%; 95% CI, 80.3-84.4). Adverse event rates were similar except for esophageal intubations and vomiting, which were both less common in VL than DL. Esophageal intubations occurred in 0.4% (95% CI 0.1-0.7) of VL attempts and 1.5% (95% CI 1.1-1.9) of DL attempts. Vomiting occurred in 0.6% (95% CI 0.5-0.7) of VL attempts and 1.4% (95% CI 0.9-1.9) of DL attempts.

CONCLUSION: Analysis of the NEAR database demonstrates higher first-pass success with VL compared to DL in patients with predicted or anatomically difficult airways, and reduced rate of esophageal intubations and vomiting.